1. The nurse is teaching a mother whose daughter has iron deficiency anemia.

The nurse determines the parent understood the dietary modifications, if she selects?

a) Bread and coffee b) Fish and Pork meat c) Cookies and milk d) Oranges and green leafy vegetables

2. Which of the following is the most common clinical manifestation of G6PD following ingestion of aspirin? a) Kidney failure b) Acute hemolytic anemia c) Hemophilia A d) Thalassemia

3. The nurse assesses a client with an ileostomy for possible development of which of the following acid-base imbalances?

a) Respiratory acidosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory alkalosis

4. The nurse anticipates which of the following responses in a client who develops metabolic acidosis.

a) Heart rate of 105 bpm b) Urinary output of 15 ml c) Respiratory rate of 30 cpm d) Temperature of 39 degree Celsius

5. A client has a phosphorus level of 5.0mg/dL. The nurse closely monitors the client for? a) b) c) d) Signs of tetany Elevated blood glucose Cardiac dysrhythmias Hypoglycemia

6. A nurse is caring for a child with pyloric stenosis. The nurse would watch out for symptoms of?

a) Vomiting large amounts b) Watery stool c) Projectile vomiting d) Dark-colored stool

7. The nurse responder finds a patient unresponsive in his house. Arrange steps for adult CPR.

a) Assess consciousness b) Give 2 breaths c) Perform chest compression d) Check for serious bleeding and shock e) Open patients airway f) Check breathing

___, ___, ___, ___, ___, ___

8. Which of the following has mostly likely occurred when there is continuous bubbling in the water seal chamber of the closed chest drainage system?

a) The connection has been taped too tightly b) The connection tubes are kinked c) Lung expansion d) Air leak in the system

9. Which if the following young adolescent and adult male clients are at most risk for testicular cancer?

a) Basketball player who wears supportive gear during basketball games b) Teenager who swims on a varsity swim team c) 20-year-old with undescended testis d) Patient with a family history of colon cancer

10. The nurse plans to frequently assess a post-thyroidectomy patient for?

a) Polyuria b) Hypoactive deep tendon reflex c) Hypertension d) Laryngospasm

11. An 18-month-old baby appears to have a rounded belly, bowlegs and slightly large head. The nurse concludes?

a) The child appears to be a normal toddler b) The child is developmentally delayed c) The child is malnourished d) The childs large head may have neurological problems.

12. A nurse is going to administer 500mg capsule to a patient. Which is the correct route?

A.)

B.)

C.)

D.)

13. An appropriate instruction to be included in the discharge teaching of a patient following a spinal fusion is? a) Dont use the stairs b) Dont bend at the waist c) Dont walk for long hours d) Swimming should be avoided

14. A nurse is preparing to give an IM injection of Iron Dextran that is irritating to the subcutaneous tissue. To prevent irritation to the tissue, what is the best action to be taken?

a) Apply ice over the injection site b) Administer drug at a 45 degree angle c) Use a 24-gauge-needle d) Use the z-track technique 15. What should a nurse do prior to taking the patients history?

a) Offer the patient a glass of water b) Establish rapport c) Ask the patient to disrobe and put on gown d) Ask pertinent information for insurance purposes

16. A pregnant woman is admitted for pre-eclampsia. The nurse would include in the health teaching that magnesium will be part of the medical management to accomplish the following? a) b) c) d) Control seizures promote renal perfusion To decrease sustained contractions Maintain intrauterine homeostasis

17. A nurse is going to administer ear drops to a 4-year-old child. What is the correct way of instilling the medicine after tilting the patients head sidewards?

a) Pull the pinna back then downwards b) Pull the pinna back then upwards c) Pull the pinna up then backwards d) Pull the pinna down then backwards

18. A nursing student was intervened by the clinical instructor if which of the following is observed?

a) Inserting a nasogastric tube b) Positioning the infant in a sniffing position c) Suctioning first the mouth, then the nose d) Squeezing the bulb syringe to suction mouth

19. Choose amongst the options illustrated below that best describes the angle for an intradermal injection?

A.)

B.)

C.)

D.)

20. During a basic life support class, the instructor said that blind finger sweeping is not advisable for infants. Which among the following could be the reason?

a) The mouth is still too small b) The object may be pushed deeper into the throat c) Sharp fingernails might injure the victim d) The infant might bite

21. A nurse enters a room and finds a patient lying on the floor. Which of the following actions should the nurse perform first? a) Call for help b) Establish responsiveness of patient c) Ask the patient what happened d) Assess vital signs

22. A patient with complaints of chest pain was rushed to the emergency department. Which priority action should the nurse do first?

a) Administer morphine sulfate intravenously b) Initiate venous access by performing venipunture c) Administer oxygen via nasal cannula d) Complete physical assessment and patient history 23. A rehab nurse reviews a post-stroke patients immunization history. Which immunization is a priority for a 72 -yearold patient?

a) Hepatitis A vaccine b) Hepatitis B vaccine c) Rotavirus Vaccine d) Pneumococcal Vaccine

24. Several patients from a reported condominium fire incident were rushed to the emergency room. Which should the nurse attend to first?

a) A 15-year-old girl, with burns on the face and chest, reports hoarseness of the voice b) A 28-year-old man with burns on all extremities c) A 4-year-old child who is crying inconsolably and reports severe headache d) A 40-year-old woman with complaints of severe pain on the left thigh

25.The doctor ordered 1 pack of red blood cells (PRBC) to be transfused to a patient. The nurse prepares the proper IV tubing. The IV tubing appropriate for blood transfusion comes with?

a) Air vent b) Microdrip chamber c) In-line filter d) Soluset

26. The expected yet negative (harmful ) result for posthemodialysis is a decrease in? a) Creatinine b) BUN c) Phosphorus d) Red blood cell count

27. A patient was brought to the emergency room after she fell down the stairs. Which of the following is the best indicator for increased intracranial pressure in head and spinal injury?

a) Inability to move extremities b) Decreased respiratory rate c) Increase in pulse and blood pressure d) Decrease level of consciousness

28. A new nurse is administering an enema to a patient. The senior nurse should intervene if the new nurse?

a) Hangs the enema bag 18 inches above the anus b) Positions the client on the right side c) Advances the catheter 4 inches into the anal canal d) Lubricates 4 inches of the catheter tip

29. The medication nurse is going to give a patient his morning medications. What is the primary action a nurse should do before administering the medications?

a) Provide privacy b) Raise head of the bed c) Give distilled water d) Check clients identification bracelet 30. A 30-year-old client is admitted with inflammatory bowel syndrome (Crohns disease). Which of the following instructions should the nurse include in the health teaching? Select all that apply a) Corticosteroid medication is part of the treatment b) Include milk in the diet c) Aspirin should be administered d) Antidiarrheal medication can help

1.) Answer: D Dark green leafy vegetables are good sources of iron. Oranges are good sources of vitamin C that enhances iron absorption in the small intestines. 2.) Answer: B Individuals with G6PD may exhibit hemolytic anemia when exposed to infection, certain medications or chemicals. Salicylates such as Aspirin damages plasma membranes of erythrocytes, leading to hemolytic anemia. 3.) Answer: B Lower GI fluids are alkaline in nature and can be lost via ileostomy. Thus, loss of HCO3, results to metabolic acidosis. 4.) Answer: C Initially, respiratory system will try to compensate metabolic acidosis. Patients with metabolic acidosis have high respiratory rate. 5.) Answer: A Normal phosphorus level is 2.5 4.5 mg/dL .The level reflects hyperphosphatemia which is inversely proportional to calcium. Client should be assessed for tetany which is a prominent symptom of hypocalcemia. 6.) Answer: C Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, constipation, and signs of dehydration, including a decrease in urine output. 7.) Answer: A, E, F, C, B, D In accordance with the new guidelines, remember AB-CABS. A-airway B-breathing normally? C-chest compression A-airway open B-breathing for patient S-serious bleeding, shock, spinal injury. The nurse should first assess consciousness of the patient. Next, open patients airway to check for breathing. When there is no breathing, immediately perform chest compression then give 2 breaths, do the cycle of care over. Finally, check for serious bleeding, shock, and spinal injury. 8.) Answer: D Continuous bubbling seen in water-seal bottle/ chamber indicates an air leak or loose connection, and air is sucked continuously into the closed chest drainage system. 9.) Answer: C Testicular cancer is most likely to affect males in late adolescence. Undescended testis is also one major risk for testicular cancer. 10.) Answer: D Hypocalcemia occurs when there is accidental removal or destruction of parathyroid tissue during surgical removal of the thyroid gland. Laryngospasm is one of the clinical manifestations of tetany, an indicator of hypocalcemia. 11.) Answer: A Its normal for a toddler to have bowlegs and a protruding belly. The head still appears somewhat large in proportion from the rest of the body. 12.) Answer: D 13.) Answer: B There is 6-8 months activity restriction following a spinal fusion. Sitting, lying, standing, normal stair climbing, walking, and gentle swimming is allowed. Bending and twisting at the waist should be avoided, along with lifting more than 10 lbs. 14.) Answer: D Z-track technique is used to administer drugs especially irritating to the subcutaneous tissue. This method promotes absorption of the drug by preventing drug leakage into the subcutaneous layer. 15.) Answer: B Establishing rapport is a way to gain trust that will lead for a patient to relax. You can get more insights and information from a patient when rapport is established. 16.) Answer: A Low magnesium (hypomagnesemia) produces clinical manifestations like increased reflexes, tremors, and seizures. Magnesium Sulfate is the drug of choice to prevent seizures in pre-eclampsia and eclampsia. 17.) Answer: C Ear canal of children ages 3years and above can be straightened by pulling the pinna up then backwards. For children below 3 years of age, the ear canal can be straightened by pulling the pinna down then backwards.

18.) Answer: A Infants are nose breathers. A gastric tube may be inserted to facilitate lung expansion and stomach decompression, but not a nasogastric tube as it can occlude the nare, thus, making breathing difficult for the infant. 19.) Answer: B 20.) Answer: B Blind finger sweeps are not recommended in all CPR cases especially for infants and children because the foreign object may be pushed back into the airway. 21.) Answer: B First step in cardiopulmonary resuscitation (CPR) is assessing responsiveness of the patient. 22.) Answer: C Priority nursing action is to administer oxygen to patients with chest pain. Chest pain is caused by insufficient myocardial oxygenation. 23.) Answer: D Pneumococcal Vaccine is a priority immunization for the elderly. Seniors, ages 65 years old and above, have higher risk for serious pneumococcal infection and likely have low immunity. This is administered every 5 years. 24.) Answer: A Burns on the face and neck can cause swelling of the respiratory mucosa that can lead to airway obstruction manifested by hoarseness of voice and difficulty in breathing. Maintaining an airway patency is the main concern. 25.) Answer: C An in-line filter is required for blood transfusions. 26.) Answer: D Negative outcome: Hemodialysis decreases red blood cell count which worsens anemia, because RBCs are lost in dialysis from anticoagulation during the procedure, and from residual blood that is left in the dialyzer. 27.) Answer: D Decrease in level of consciousness and headache are early signs of increase in intracranial pressure (ICP). Altered level of consciousness is the most common symptom that indicates a deficit in brain function. 28.) Answer: B Recall the anatomy of the colon. The appropriate position is left lateral to facilitate flow of enema by gravity into the colon. 29.) Answer: D Recall the 12 Rights of administration. Checking the patients name is critical for client -safety. 30.) Answer: A , D Crohns disease is a chronic inflammation of the colon with symptoms of diarrhea, abdominal pain, and weight loss. Corticosteroid is a treatment for Crohns disease. Antidiarrheal can give relief to diarrheal episodes. Aspirin should be avoided as it can worsen inflammation. Those with Crohns disease are mostly lactose intolerant, so choice no. (2) is incorrect.

Physical Assessment Techniques

(Nettina, 2006)

Inspection Scrutinize the patients body and behavior. Be highly sensitive to visual clues. Palpation Touch without or with pressure (as indicated) the region or body part to be observed and note for tenderness and what the various structures feel like. Percussion Determine the density of the underlying tissues and whether it is air-filled, fluid-filled or solid with the use of audible sounds and palpable vibrations being produced. Distinguish the different qualities of sound, pitch, duration and intensity. Auscultation Use stethoscope to augment the sense of hearing. Use the bell for low-pitched sounds like heart murmurs while the diaphragm screen for low-pitched and high-frequency sounds like breath sounds and pulses.

ASSESSING FROM HEAD-TO-TOE (CEPHALO-CAUDAL) (Nettina, 2006)

Assess vital signs 1. 2. 3. 4. Temperature identify whether hypothermia, normothermia and hyperthermia Pulse assess if the pulse is full, strong, weak, bounding or thready. Respiration note for the rhythm, breath sounds and depth of breathing. Blood pressure measures hypotension, BP within normal range and hypertension.

Obtain the height, weight and BMI of the patient. Inspect for the General Appearance - Observe for race, sex, general physical development, nutritional state, mental alertness, affect, evidence of pain, restlessness, body position, clothes, apparent age, hygiene and grooming.

Review of Systems
Neurologic with the use of GLASGOW COMA SCALE. Assess the mental status, cranial nerve function, cerebellar function, motor function, sensory function and deep tendon reflexes. Integumentary Inspect for skin color, pigmentation, lesions (distribution, type, configuration, size), jaundice, cyanosis, scars, superficial vascularity, hydration, edema, color of mucous membranes, hair distribution and nails. Palpate skin for temperature, texture, elasticity and turgor. Peripheral Circulation Palpate for jugular vein distention and pulsations. Observe for skin color, temperature, hair distribution, pallor, rubor and swelling. Palpate pulses. Palpate for edema and masses Head Inspect for the symmetry of face, configuration of skull, hair color and distribution, scalp. Palpate for hair texture, masses, swelling or tenderness of scalp and configuration of the skull. Eyes and Vision Inspect globes for protrusion; palpebral fissures for width and symmetry; lid margins for scaling, secretions, erythema, and position of lashes; bulbar and palpebral conjunctiva for congestion and color; sclera and iris for color; pupils for size, shape, symmetry, reaction to light and accommodation PERRLA (Pupil Equally Round and Reactive to Light Accomodation); eye movement for extraocular movements, nystagmus and convergence; gross visual fields by donfrontation; and the visual acuity with the use of Snellen chart (with and without glasses). Determine the strength of the upper lids by attempting to open closed lids against resistance. Palpate globes through closed lids for the tenderness and tension. Ears and Hearing Inspect for the size, shape, color, symmetry, placement on the head, lesions, tenderness, consistency of the cartilage, swelling and masses. Examine for the presence of discharges, impacted cerumen, inflammation, masses or foreign bodies. Examine hearing by mechanical tests such as whisper or watch tic-tac test, weber and rhine tests. Nose and Sinuses Inspect for general deformity, position and perforation, discharges, obstruction, airway patency, color of the mucus membranes and the turbinates for swelling. Palpate sinuses for swelling and tenderness. Mouth Inspect for the lips color, moisture, pigment, masses, ulcerations and fissures. Check for the number, arrangement and general condition of the teeth. Observe for gums color, texture, discharge, swelling or retraction. Buccal mucosa should be observed for discoloration, vesicles, ulcers and masses. Pharynx for inflammation, exudates and masses. Tongue for its ability to protrude, size, color, thickness, lesions, moisture, symmetry, deviations from midline, fasciculation. Check for the patency of the salivary glands. Uvula should be symmetry when

the patient says ah. Check the size, ulcerations, exudates and inflammation of the tonsils. The odor of the breath and the hoarseness of the voice should be examined. Neck Inspect for the symmetry and range of motion. Palpate for masses, pulsations and jugular vein distention. Auscultate to listen for bruits over the carotid arteries. Lymph Nodes Inspect and palpate for the size, shape, mobility, consistency, tenderness and inflammation. Breasts For female, inspect the areola and nipples for position, pigmentation, inversion, discharge, crusting and masses. Check for size, shape, color, symmetry, surface, contour, skin characteristics and level of breast. Observe for retraction or dimpling of the skin. Palpate for the tissue distribution, masses, inflammation and engorgement. Note for skin texture, moisture and temperature. For male, inspect the nipple and areola for ulceration, nodules, swelling or discharge and tenderness. Thorax and Lungs Inspect for the ribs mobility, structural deformity, symmetry, bulges or retractions, respiration and impairment of the respiratory movement. Palpate for tenderness, masses and inflammation. Assess respiratory expansion. Elicit vocal and tactile fremitus by asking the patient to say 99. Percuss the chest and observe the percussion sounds for both sides. Observe for the resonance, tymphanism and dullness of percussion sounds. Auscultate the breath sounds and identify the vesicular, bronchovesicular and bronchial or tubular. Heart Inspect the precordium for any bulging, heaving or thrusting and note for any other pulsations. Palpate for the vibrations and pulsations over aortic, pulmonic, tricuspid and mitral. Percussion to identify heart border and area of cardiac dullness. Auscultate for the rhythm and rate of the pulses, heart and the heart sounds. Abdomen Observe for the general contour of the abdomen, symmetry, visible peristalsis and aortic pulsations. Inspect the umbilicus for contour or hernia and the skin for rashes, striae and scars. Auscultate for bowel sounds, note the character and frequency of bowel sounds including the pitch and duration. Auscultate the aorta and renal arteries found at the upper quadrants and iliac arteries at the lower quadrants. Percuss the four abdominal quadrants noting its resonance, dullness and tymphanism. Perform light palpation to detect any muscular resistance or guarding, tenderness or superficial organs or masses. Deep palpation to assess location, size, shape, consistency, tenderness, pulsations and mobility of underlying organs and masses. Genitalia Inspect for the skin color and temperature, pubic hair distribution, ulcers, masses, scars, redness, swelling and discharges. Also, for the size and shape irregularities. Palpate for lesions, nodules or masses, tenderness, contour, size and induration. Palpate the inguinal area and anterior thigh. Rectum Inspect and palpate the anus, perianal region and sacral region for inflammation, nodules, scars, ulcerations, lesions and rashes or for any abnormal opening. Note any bulges after bearing down. Musculoskeletal Inspect the upper and lower extremities for size, shape, symmetry, deformity and muscle mass. Check the joints for range of motion, enlargement and masses. Note gait and posture. Check the spine for range of motion, lateral curvature, or any abnormal curvature. Observe for the signs of pain and inflammation. Palpate for tenderness, swelling, warmth, bony overgrowth, deformity and masses. Palpate the muscles for size, tone, strength, any contractures and tenderness. Palpate the spine for bony deformities and crepitation.

LANDMARKS FOR PHYSICAL EXAMINATION

Apices and bases of the lungs The structural landmarks of the chest are clavicle, midsternal line, right/left anterior axillary line and the midclavicular line. On the sides, are posterior axillary line, midaxillary line and anterior axillary line. The anteroposterior (AP) diameter of the thorax in relation to the lateral diameter is approximately 1:2. Apices of the lungs the land marks are manubrium, sternal notch and angle of Louis to assess the right/left upper lung lobes. Bases of the lungs the land marks are xiphoid process, body of sternum and 4-7th ribs to assess the right/left lower lung lobes (Nettina, 2006; Laurente et al., 1997). Horizontally, thoracic locations are identified according to their proximity to the rib or the intercostal space under the examiners fingers. On the anterior surface, identification of a specific rib is facilitated by first locating the angle of Louis. This is where the manubrium joins the body of the sternum in the midline. The second rib joins the sternum at this prominent landmark. Other ribs may be identified by counting down from the second rib. The intercostal spaces are referred to in terms of the rib immediately above the intercostal space; for example, the fifth intercostals space is directly below the fifth rib. Locating ribs on the posterior surface of the thorax is more difficult. The first step is to identify the spinous process. This is accomplished by finding the seventh cervical vertebra (vertebra prominens),

which is the most prominent spinous process. When the neck is slightly flexed, the seventh cervical spinous process stands out. Other vertebrae are then identified by counting downward (Smeltzer & Bare, 2004).

Vertical landmarks start at the midsternal line passes through the center of the sternum. The midclavicular line is an imaginary line that descends from the middle of the clavicle. The point of maximal impulse of the heart normally lies along this line on the left thorax. When the arm is abducted from the body at 90, imaginary vertical lines may be drawn from the anterior axillary fold, from the middle of the axilla, and from the posterior axillary fold. These lines are called, respectively, the anterior axillary line, the midaxillary line, and the posterior axillary line. A line drawn vertically through the superior and inferior poles of the scapula is called the scapular line, and a line drawn down the center of the vertebral column is called the vertebral line. Using these landmarks, for example, the examiner communicates findings by referring to an area of dullness extending from the vertebral to the scapular line between the seventh and tenth ribs on the right (Smeltzer & Bare, 2004).

The line between the upper and lower lobes on the left begins at the fourth thoracic spinous process posteriorly, proceeds around to cross the fifth rib in the midaxillary line, and meets the sixth rib at the sternum. This line on the right divides the right middle lobe from the right lower lobe. The line dividing the right upper lobe from the middle lobe is an incomplete one that begins at the fifth rib in the midaxillary line, where it intersects the line between the upper and lower lobes and traverses horizontally to the sternum. Thus, the upper lobes are dominant on the anterior surface of the thorax and the lower lobes are dominant on the posterior surface. There is no presentation of the middle lobe on the posterior surface of the chest (Smeltzer & Bare, 2004).

Auscultating Normal Heart Sounds

First heart sound Second heart sound

To visualize the position of the heart under the sternum and the ribs, locate the intercostals spaces by identifying the angle of Louis felt as a slight ridge approximately 1 inch below the sternal notch where the manubrium and the body of the sternum are joined. The 2nd ribs extend to the right and left of this angle. Locate the 2nd rib, palpate downward and obliquely away from the sternum to identify the remaining ribs and intercostals spaces. Apical impulse can be located on the 5-6th intercostals space or just medial to the midclavicular line. Heart sounds can be auscultated over the pulmonic or aortic area. S1 is caused by the closing of the tricuspid and mitral valves. S 2 results from the closing of the aortic and pulmonary valves. Aortic area found at the 2 nd right intercostals space, close to the sternum. Pulmonic area is at the 2nd left intercostals space. Mitral area is the apex of the heart found at the 5 th intercostals space or just medial to the midclavicular line, the apical beat (the point of maximal impulse). Tricuspid area is at the 5 th intercostal space next to the sternum. The Erbs point can be heard over the 3rd interspace close to the sternum. S1 and S2 are heard as lub dub. In the aortic and pulmonic areas, S2 is usually louder than S1. In the tricuspid area, S1 and S2 are of almost equal in intensity and in the mitral area, S1 is often slightly louder than S2 (Nettina, 2006; Laurente et al., 1997).

Auscultating Bowel Sounds

Bowel sounds can be heard like growling sounds over the entire four quadrants of the abdomen (Nettina, 2006). The right lower quadrant (RLQ) is the best site to auscultate bowel sounds for immediate examination (Hayes, 2007). All areas (4 quadrants) should be assessed to examine the entire colon and to determine the area of obstruction.

Area of Liver Palpation

Palpate the liver by placing the left hand under the patients lower right rib cage and the right hand on the abdomen below the level of liver dullness (Nettina, 2006).

CLINICAL IMPLICATIONS AND RELEVANCE OF PHYSICAL ASSESSMENT PARAMETERS

Level of Consciousness
Level of consciousness is gauged on a continuum with a normal state of alertness and full cognition (consciousness) on one end and coma on the other end. The level of consciousness can be an indication of the hearts ability to propel oxygen to the brain (cerebral perfusion). LOC is a very significant indicator of oxygenation and tissue perfusion. It is also necessary to detect evidence of neurologic problem, infection (sepsis), bleeding, decreased circulating blood, and fluid volume and cardiac output. The level of responsiveness and consciousness is the most important indicator of the patients condition (Smeltzer & Bare, 2004).

Breathing Patterns
The rate and depth of respiration or the breathing pattern is a simple but important aspect of assessment. The normal breathing pattern is called eupnea. Bradypnea (slow breathing) is associated with increased intracranial pressure, brain injury and drug overdose. Tachypnea (rapid breathing) is commonly seen in patients with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, and rib fracture. Hypoventilation has shallow and irregular breathing. An increase in depth of respirations is called hyperpnea. An increase in both rate and depth that a result in a lowered arterial PCO2 level is referred to as hyperventilation. With rapid breathing, inspiration and expiration are nearly equal in duration. Hyperventilation that is marked by an increase in rate and depth, associated with severe acidosis of diabetic or renal origin, is called Kussmauls respiration. Apnea describes varying periods of cessation of breathing. If sustained, apnea is life-threatening. Cheyne-Stokes respiration is characterized by alternating episodes of apnea (cessation of breathing) and periods of deep breathing. Cheyne-Stokes respiration is usually associated with heart failure and damage to the respiratory center (drug-induced, tumor, trauma). Biots respirations, or cluster breathing, are cycles of breaths that vary in depth and have varying periods of apnea. Biots respirations are seen with some central nervous system disorders. Certain patterns of respiration are characteristic of specific disease states (Smeltzer & Bare, 2004).

Breath sounds vary according to proximity of the large bronchi. Breath sounds are louder and coarser near the large bronchi and over the anterior. It is softer and much finer (vesicular) at the periphery over the alveoli. Vesicular breath sound has low pitch with soft intensity and located all over the lungs. Bronchovesicular has medium pitch with medium intensity heard near the main stem bronchi (below the clavicles and between the scapulae, especially on the right). Bronchial or tubular has high pitch and loud heard over the trachea. A disease will alter the normal bronchial, bronchovesicular and ventricular breath sounds. Adventitious sounds may indicate crackles, wheezes and ronchi. Sounds may normally decrease in obese patients (Nettina, 2006; Laurente et al., 1997).

Peripheral Perfusion
Assessing peripheral perfusion such as skin color, capilly refill, temperature and sensations are indicators of peripheral oxygenation and venous / arterial blood flow. This will also detect if the blood vessels are constricted or dilated. This helps to assess the peripheral system blood flow and its ability and capacity to maintain an adequately circulating blood volume for tissue oxygenation. Also, this will help to assess not only the blood volume of the body but the ability of the heart to pump blood and test the functions of the cardio-pulmonary and hematologic system (Smeltzer & Bare, 2004).

Assymetrical Chest Expansion

Chest movement should be symmetric and without lag or impairment (Nettina, 2006). It is quite normal to see a slight retraction of the intercostal spaces during quiet breathing of thin patient. Bulging during expiration implies obstruction of expiratory airflow as seen in emphysema. Marked retraction on inspiration, particularly if asymmetric, implies blockage of a branch of the respiratory tree. Asymmetric bulging of the intercostal spaces, on one side or the other, is created by an increase in pressure within the hemithorax. This may be a result of air trapped under pressure within the pleural cavity where it does not normally appear (pneumothorax) or the pressure of fluid within the pleural space (pleural effusion). Respiratory excursion is an estimation of thoracic expansion and may disclose significant information about thoracic movement during breathing. This movement is normally symmetric. Decreased chest

excursion may be due to chronic fibrotic disease. Asymmetric excursion may be due to splinting secondary to pleurisy, fractured ribs, trauma, or unilateral bronchial obstruction (Smeltzer & Bare, 2004).

Jugular Vein Distention

Jugular vein distention can be an indication for a suspected compromise cardiac function (Nettina, 2006). When the right ventricle fails, congestion of the viscera and the peripheral tissues predominates. This occurs because the right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. The increase in venous pressure leads to jugular vein distention (JVD). JVD is associated with fluid volume overload and pulmonary congestion or edema. Also, it is associated with right-sided heart failure. Jugular vein distention is a sign of fluid and electrolyte imbalances and compromised regulatory mechanisms such as renal failure, heart failure, and cirrhosis and overzealous administration of sodium-containing fluids. Prolonged corticosteroid therapy, severe stress, and hyperaldosteronism augment fluid volume excess (Smeltzer & Bare, 2004).