Gerontological Nursing Exam Sample QuestionsThe following sample questions are similar to those on the examination but do not represent the full range of content or levels of difficulty. The answers to the sample questions are provided after the last question. Please note: Taking these or any sample question(s) is not a requirement to sit for an actual certification examination. Completion of these or any other sample question(s) does not imply eligibility for certification or successful performance on any certification examination. Show
To respond to the sample questions, first enter your first and last names in the boxes below (this information will not be recorded; it is strictly for purposes of identifying your results). Then click the button corresponding to the best answer for each question. When you are finished, click the "Evaluate" button at the bottom of the page. A new browser window will open, displaying your results, which you may print, if you wish. This practice exam is not timed, and you may take it as many times as you wish. Good luck! The NMC has included chest auscultation and interpretation in the Standards of Proficiency for future registered nurses. This article offers a practical guide to the procedure AbstractChest auscultation is frequently used in the clinical examination of patients. This article explains the clinical procedure for chest auscultation and provides a guide to interpreting findings. Citation: Proctor J, Rickards E (2020) How to perform chest auscultation and interpret the findings. Nursing Times [online]; 116: 1, 23-26.. Authors: Jaclyn Proctor is respiratory advanced nurse practitioner at Warrington and Halton NHS Foundation Trust; Emma Rickards is respiratory nurse consultant at Liverpool Heart and Chest Hospital NHS Foundation Trust and Knowsley Community Respiratory Service.
IntroductionAlthough the first stethoscope for auscultation was invented in 1816 by René-Théophile-Hyacinthe Laennec, the use of auscultation dates back to Hippocrates, who would place his ear to his patient’s chest and listen for sounds. Auscultation is an important part of an assessment of the respiratory system and is also used for cardiac and gastrointestinal examination. The procedure should always form part of an holistic assessment and must be viewed alongside the patient’s clinical history (Box 1). Box 1. IPPA assessment A commonly used acronym in clinical examination of the chest is IPPA:
This is an example of a systemic assessment tool but other tools are available (Simpson, 2015) The Nursing and Midwifery Council (2018) has included chest auscultation and interpretation of findings in the Standards of Proficiency for Registered Nurses, and student nurses now learn this skill as undergraduates. To undertake a thorough assessment of the chest, including auscultation, it is essential to understand the anatomy and physiology of the respiratory system. Fig 1 illustrates the anatomy of the lungs and Fig 2 highlights the location of the lung lobes from an anterior chest perspective. Cedar (2018) provides further information on the physiology of breathing.  What is chest auscultation?Vesicular breath sounds occur when the vocal cords vibrate during inspiration and expiration, when the vibrations are transmitted to the trachea and bronchi. These sounds are audible when auscultation is performed using a stethoscope. Chest auscultation involves listening to these internal sounds to assess airflow through the trachea and the bronchial tree (Sarkar et al, 2015). Familiarity with the normal vesicular breath sounds found at specific locations on the chest enables health professionals to identify abnormal sounds, which are often referred to as adventitious. It is not always possible to determine from which lobe of a lung a sound is emanating. Using the four chest X-ray zones can, therefore, be helpful:
EquipmentThe bell of the stethoscope is generally used to detect high-pitched sounds – at the apex of the lungs above the clavicle; its diaphragm is used to detect low-pitched sounds in the rest of the chest (Dougherty and Lister, 2015). Fig 3 illustrates parts of the stethoscope. Infection preventionThe stethoscope is an important tool for clinical assessment, but can become contaminated by micro-organisms (Longtin et al, 2014). Adherence to local infection prevention and control policies, including the cleaning of equipment between every patient contact, is essential. Nurses are advised to have a stethoscope for their own use, as sharing equipment may increase infection risk and maintaining clean ear tips can be difficult. Non-sterile gloves are not required routinely for this procedure. Nurses need to assess individual patients for the risk of exposure to blood and body fluids (Royal College of Nursing, 2018) and to be aware of local policies for glove use. Preparing the environment and patientListening to a patient’s chest to establish breath and any other sounds requires a quiet area, so that health professionals can fully appreciate what they hear and interpret their clinical relevance (Sarkar et al, 2015). Chest auscultation requires the chest and back to be exposed, so measures should be taken to ensure the patient’s privacy and dignity is maintained at all times. A chaperone should be offered for the assessment if this is considered appropriate. Positioning the patientThe optimal position for chest auscultation is sitting in a chair, or on the side of the bed. However, the patient’s clinical condition and comfort needs to be considered during the examination and some patients may only tolerate lying at a 45° angle. Both these positions will facilitate the assessment (Ferns and West, 2008). You may need help to support the patient in a comfortable position during the examination. The procedure
Box 2. Recording the findings of chest auscultation Accurate recording is essential to enable clinical comparison to be made when the patient is reassessed (Table 1). It is important to record:
Interpreting findingsThere are several adventitious sounds but the main ones to be aware of are crackles, wheeze and absent breath sounds. CrackleCrackles are generated within the small airways; they predominantly occur during the inspiratory phase but can happen on expiration. Clinical conditions where crackles maybe present include pneumonia, pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), lung infection and heart failure. Crackles can be categorised as coarse or fine; distinguishing between these can be significant – coarse crackles may indicate pneumonia, while fine crackles may suggest pulmonary oedema. It takes practice to learn to differentiate between coarse and fine crackles and interpretation remains subjective. WheezeWheeze often occurs on expiration, but can also occur on inspiration. Wheezing is often louder than usual breath sounds and in some patients it is audible from some distance or when the patient breathes through the mouth. With a stethoscope you may also be able to hear a wheeze over the patient’s trachea (Sarkar et al, 2015). Wheeze is often referred to as a musical sound and is sometimes considered to be a precondition for conditions such as airflow obstruction (Simpson, 2015). Clinical conditions such as asthma are associated with a high-pitched musical wheeze that may be more evident on expiration. An inspiratory wheeze (stridor) usually results from an upper airway obstruction such as laryngeal oedema or the presence of a foreign body. A wheeze on both inspiration and expiration could be due to secretions in the airways (Welch and Black, 2017) and the patient may need to be advised how to clear their chest of secretions. Absent breath soundsThis describes a lack of audible breath sounds on auscultation. It could be caused by lung disorders that inhibit the transmission of sounds, for example, a pneumothorax, pleural effusion or areas of lung consolidation. All these conditions prevent airflow reaching parts of the lung due to a pathological change in the function of the lung. Case studiesEmma Green*, aged 65, attended the emergency department with history of a productive cough for five days, reduced exercise tolerance and increased breathlessness. She reported pain on right lower aspect of the posterior chest. On assessment, Ms Green reported no underlying respiratory disease. Chest auscultation identified reduced air entry on the right lower lobe and additional coarse crackles on inspiration in the right mid zone. In this case the auscultation findings and clinical history suggest a diagnosis of pneumonia. Raphael Garbet*, aged 45, was admitted via his GP with increased breathlessness and an audible wheeze. He had recently started treatment for asthma. His symptoms had been present for 24 hours and he had been using his salbutamol inhaler but remained symptomatic. His personalised asthma action plan suggested he should visit his GP. On assessment, Mr Garbet was using accessory muscles to breathe and was pale. He was only able to complete short sentences and was breathless at rest. Chest auscultation revealed inspiratory/expiratory wheeze in all lung fields on the left and right side. In this case, the auscultation findings along the clinical history suggest a diagnosis of acute exacerbation of asthma. * The patients’ names have been changed References Cedar SH (2018) Every breath you take: the process of breathing explained. Nursing Times; 114: 1, 47-50. Dougherty L, Lister S (2015) The Royal Marsden Manual of Clinical Nursing Procedures. Chischester: Wiley. Ferns T, West S (2008) The art of auscultation evaluating a patient’s respiratory pathology. Longtin Y et al (2014) Contamination of stethoscopes and physician’s hands after a physical examination. Mayo Clinic Proceedings; 89: 291-299. Nursing and Midwifery Council (2018) Future Nurse: Standards of Proficiency for Registered Nurses. Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Professionals on Glove Use and the Prevention of Contact Dermatitis. London: RCN. Sarkar M (2015) Auscultation of the respiratory system. Annals of Thoracic Medicine; 10: 3, 158-168. Simpson H (2015) Respiratory assessment. British Journal of Nursing; 15: 9, 484-488. Welch J, Black C (2017) Respiratory problems. In: Adam S et al (eds) Critical Care Nursing Science and Practice. Oxford: Oxford University Press. What happens to the respiratory system during aging?There are several body changes that happen as you get older that may cause a decline in lung capacity: Alveoli can lose their shape and become baggy. The diaphragm can, over time, become weaker, decreasing the ability to inhale and exhale. This change will only be significant when exercising.
What are normal respiratory findings?The normal range of a respiratory rate for an adult is 12-20 breaths per minute at rest, and the normal range for oxygen saturation of the blood is 94–98% (SpO₂) Bradypnea is less than 12 breaths per minute, and tachypnea is greater than 20 breaths per minute.
Which of the following are respiratory changes in aging?Effects of Aging on the Respiratory System. Decreases in peak airflow (how quickly someone can exhale) and exchange of carbon dioxide and oxygen. ... . Decreases in measures of lung function. ... . Weakening of the respiratory muscles. ... . Decline in the effectiveness of lung defense mechanisms.. Does residual volume increase with age?Functional residual capacity and residual volume increase with age, resulting in a lower vital capacity.
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