NURS 480 exam 1 Latest recent and
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,Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon
after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patients breath sounds.
d. Give the prescribed PRN morphine sulfate IV. - correct ans:ANS: C
The initial action should be to assess the patient further because the history and symptoms are
consistent with several possible complications of central line insertion, including embolism and
pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed
before notifying the health care provider, offering reassurance, or administration of morphine
The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which
action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. - correct ans:ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when
the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then
auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be
noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia,
, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is
an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is
decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of
the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast
tissue.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most
concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site - correct ans:ANS: B
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock.
An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially,
brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be
treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous
emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of
subcutaneous air is harmless and will be reabsorbed.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the
suction-control chamber of the collection device. Which action by the nurse is most appropriate?
a. Document the presence of a large air leak.
b. Notify the surgeon of a possible pneumothorax.
c. Take no further action with the collection device.
frequently tested with comprehensive
questions and verified accurate solution
(detailed & elaborated) GRADED A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
CONTACT INFORMATION
WHATAPPSLINK- https://wa.me/254784769540
,Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon
after insertion of a centrally inserted IV catheter?
a. Notify the health care provider.
b. Offer reassurance to the patient.
c. Auscultate the patients breath sounds.
d. Give the prescribed PRN morphine sulfate IV. - correct ans:ANS: C
The initial action should be to assess the patient further because the history and symptoms are
consistent with several possible complications of central line insertion, including embolism and
pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed
before notifying the health care provider, offering reassurance, or administration of morphine
The nurse palpates the posterior chest while the patient says 99 and notes absent fremitus. Which
action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. - correct ans:ANS: D
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when
the patient repeats a word or phrase such as 99. After noting absent fremitus, the nurse should then
auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be
noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia,
, lung tumors, thick bronchial secretions, and pleural effusion. Turning, coughing, and deep breathing is
an appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is
decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of
the chest is more difficult to palpate for fremitus because of the presence of large muscles and breast
tissue.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most
concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site - correct ans:ANS: B
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock.
An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially,
brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be
treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous
emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of
subcutaneous air is harmless and will be reabsorbed.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the
suction-control chamber of the collection device. Which action by the nurse is most appropriate?
a. Document the presence of a large air leak.
b. Notify the surgeon of a possible pneumothorax.
c. Take no further action with the collection device.
