NUR417 Exam 3
A patient describes his involvement in a situation that the nurse suspects demonstrates the sexual abuse
of a child. What is the nurse's initial response?
A. Verify that the event actually occurred.
B. Consider the negative effects of breeching patient trust.
C. Report the suspected abuse to the appropriate agency.
D. Notify the health care provider of the statemen *** Report the suspected abuse to the appropriate
agency. Correct
The nurse is legally obligated to report suspected and actual sexual abuse of children to police or
appropriate agencies. All states have mandatory child abuse reporting statutes. It is not the nurse's
responsibility to verify the event. The primary concern is for the child, even if that means compromising
confidentiality.
The nurse caring for an older adult suspects elder abuse. Which action is appropriate?
A. Collect proof of abuse before notifying the authorities.
B. Confront the caretakers about the suspicion of abuse.
C. Notify the authorities of the suspected elder abuse.
D. Report the abuse if the older adult gives permission. *** C. The nurse is a mandatory reporter of
elder abuse and should notify the authorities of suspected elder abuse.The nurse does not need proof of
abuse before calling the authorities.The nurse should not confront the caretakers if elder abuse is
suspected.The nurse does not need permission from the elder before calling the authorities.
You are working with a child and suspect physical abuse. What is your primary legal responsibility?
A. Document your assessment thoroughly and accurately.
B. Report the abuse to local authorities.
C. Refer the family to support groups.
D. Assist the family in identifying resources and support systems. *** Answer: B - The nurse should
report her suspicions to the local authorities so they can investigate. The law makes it mandatory to
,report any suspected child abuse. All other options are important in dealing with patient and the family,
but they would not be the priority of the nurse.
Which action should the nurse plan to prevent aspiration in a high-risk patient?
a. Turn and reposition an immobile patient at least every 2 hours.
b. Place a patient with altered consciousness in a side-lying position.
c. Insert a nasogastric tube for feeding a patient with high calorie needs.
d. Monitor respiratory symptoms in a patient who is immunosuppressed. *** b. Place a patient with
altered consciousness in a side-lying position.
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to
occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are
placed in a side-lying or upright position.
An occupational health nurse works at a manufacturing plant where there is potential exposure to
inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?
a. Treat workers with pulmonary fibrosis.
b. Teach about symptoms of lung disease.
c. Require the use of protective equipment.
d. Monitor workers for coughing and wheezing. *** c. Require the use of protective equipment.
The nurse monitors a patient in the emergency department 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 *** b. 400 mL of blood in the collection chamber
,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
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat.
The emergency department nurse would be most concerned if which finding is observed during the
initial assessment?
a. Paradoxical chest movement c. Heart rate of 110 beats/minute
b. Complaint of chest wall pain d. Large bruised area on the chest *** a. Paradoxical chest movement
Paradoxical chest movement indicates that the patient may have flail chest, which can severely
compromise gas exchange and can rapidly lead to hypoxemia. When a person has a flail chest, the nurse
should stabilize the chest with positive pressure and call a surgeon for surgery.
When assessing a patient who has just arrived after an *automobile accident*, the emergency
department nurse notes tachycardia and *absent breath sounds* over the right lung. For which
intervention will the nurse prepare the patient?
a. Emergency pericardiocentesis
c. Bronchodilator administration
b. Stabilization of the chest wall
d. Chest tube connected to suction *** d. Chest tube connected to suction
The patient's history and *absent breath sounds* suggest a *right-sided pneumothorax* or
hemothorax, which will require treatment with a *chest tube and drainage to suction*.
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-
control chamber of the collection device. Which action by the nurse is appropriate?
a. Adjust the dial on the wall regulator.
b. Continue to monitor the collection device.
c. Document the presence of a large air leak.
, d. Notify the surgeon of a possible pneumothorax. *** b. Continue to monitor the collection device.
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control
chamber is connected to suction.
The nurse provides *preoperative instruction* for a patient scheduled for a *left pneumonectomy*.
Which information should the nurse include about the patient's postoperative care?
a. Bed rest for the first 24 hours
b. Positioning only on the right side
c. Frequent use of an incentive spirometer
d. Chest tube placement to continuous suction *** c. Frequent use of an incentive spirometer
Frequent *deep breathing* and coughing are needed after *chest surgery* to *prevent atelectasis*.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The
nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42
breaths/min. Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient's health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position. *** d. Elevate the head of the bed to a semi-
Fowler's position.
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed
will improve ventilation and gas exchange. The other actions can be accomplished after the head is
elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE.
Anticoagulants may be ordered after confirmation of the diagnosis of PE.
A patient describes his involvement in a situation that the nurse suspects demonstrates the sexual abuse
of a child. What is the nurse's initial response?
A. Verify that the event actually occurred.
B. Consider the negative effects of breeching patient trust.
C. Report the suspected abuse to the appropriate agency.
D. Notify the health care provider of the statemen *** Report the suspected abuse to the appropriate
agency. Correct
The nurse is legally obligated to report suspected and actual sexual abuse of children to police or
appropriate agencies. All states have mandatory child abuse reporting statutes. It is not the nurse's
responsibility to verify the event. The primary concern is for the child, even if that means compromising
confidentiality.
The nurse caring for an older adult suspects elder abuse. Which action is appropriate?
A. Collect proof of abuse before notifying the authorities.
B. Confront the caretakers about the suspicion of abuse.
C. Notify the authorities of the suspected elder abuse.
D. Report the abuse if the older adult gives permission. *** C. The nurse is a mandatory reporter of
elder abuse and should notify the authorities of suspected elder abuse.The nurse does not need proof of
abuse before calling the authorities.The nurse should not confront the caretakers if elder abuse is
suspected.The nurse does not need permission from the elder before calling the authorities.
You are working with a child and suspect physical abuse. What is your primary legal responsibility?
A. Document your assessment thoroughly and accurately.
B. Report the abuse to local authorities.
C. Refer the family to support groups.
D. Assist the family in identifying resources and support systems. *** Answer: B - The nurse should
report her suspicions to the local authorities so they can investigate. The law makes it mandatory to
,report any suspected child abuse. All other options are important in dealing with patient and the family,
but they would not be the priority of the nurse.
Which action should the nurse plan to prevent aspiration in a high-risk patient?
a. Turn and reposition an immobile patient at least every 2 hours.
b. Place a patient with altered consciousness in a side-lying position.
c. Insert a nasogastric tube for feeding a patient with high calorie needs.
d. Monitor respiratory symptoms in a patient who is immunosuppressed. *** b. Place a patient with
altered consciousness in a side-lying position.
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to
occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are
placed in a side-lying or upright position.
An occupational health nurse works at a manufacturing plant where there is potential exposure to
inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?
a. Treat workers with pulmonary fibrosis.
b. Teach about symptoms of lung disease.
c. Require the use of protective equipment.
d. Monitor workers for coughing and wheezing. *** c. Require the use of protective equipment.
The nurse monitors a patient in the emergency department 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 *** b. 400 mL of blood in the collection chamber
,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
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat.
The emergency department nurse would be most concerned if which finding is observed during the
initial assessment?
a. Paradoxical chest movement c. Heart rate of 110 beats/minute
b. Complaint of chest wall pain d. Large bruised area on the chest *** a. Paradoxical chest movement
Paradoxical chest movement indicates that the patient may have flail chest, which can severely
compromise gas exchange and can rapidly lead to hypoxemia. When a person has a flail chest, the nurse
should stabilize the chest with positive pressure and call a surgeon for surgery.
When assessing a patient who has just arrived after an *automobile accident*, the emergency
department nurse notes tachycardia and *absent breath sounds* over the right lung. For which
intervention will the nurse prepare the patient?
a. Emergency pericardiocentesis
c. Bronchodilator administration
b. Stabilization of the chest wall
d. Chest tube connected to suction *** d. Chest tube connected to suction
The patient's history and *absent breath sounds* suggest a *right-sided pneumothorax* or
hemothorax, which will require treatment with a *chest tube and drainage to suction*.
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-
control chamber of the collection device. Which action by the nurse is appropriate?
a. Adjust the dial on the wall regulator.
b. Continue to monitor the collection device.
c. Document the presence of a large air leak.
, d. Notify the surgeon of a possible pneumothorax. *** b. Continue to monitor the collection device.
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control
chamber is connected to suction.
The nurse provides *preoperative instruction* for a patient scheduled for a *left pneumonectomy*.
Which information should the nurse include about the patient's postoperative care?
a. Bed rest for the first 24 hours
b. Positioning only on the right side
c. Frequent use of an incentive spirometer
d. Chest tube placement to continuous suction *** c. Frequent use of an incentive spirometer
Frequent *deep breathing* and coughing are needed after *chest surgery* to *prevent atelectasis*.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The
nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42
breaths/min. Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient's health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position. *** d. Elevate the head of the bed to a semi-
Fowler's position.
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed
will improve ventilation and gas exchange. The other actions can be accomplished after the head is
elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE.
Anticoagulants may be ordered after confirmation of the diagnosis of PE.
