NUR 417 Nursing Care of the Adult II
NUR 417 FINAL EXAM LATEST-
NURSING CARE OF THE ADULT II 2026
COMPLETE QUESTION AND ANSWER
(REAL EXAM)
The health care provider inserts a chest tube in a patient with a hemo-pneumothorax.
When
monitoring the patient after the chest tube placement, which of the following findings is of
greatest concern?
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
ANS: B
The large amount of blood may indicate that the patient is in danger of developing
hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care
provider. A large air leak would be expected immediately after chest tube placement for
pneumothorax. 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.
The nurse is caring for a patient who has a steering wheel injury as a result of an
automobile
accident. Which of the following findings should be of most concern to the nurse during the
initial assessment?
a. Paradoxical chest movement
b. The complaint of chest wall pain
c. A heart rate of 110 beats/minute
d. A large bruised area on the chest
ANS: A
Paradoxical chest movement indicates that the patient may have flail chest, which can
severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a
slightly elevated pulse rate, and chest bruising all require further assessment or
intervention,
but the priority concern is poor gas exchange.
,NUR 417 Nursing Care of the Adult II
The nurse is assessing a patient who has just arrived after an automobile accident and the
nurse notes that the breath sounds are absent on the right side. Which of the following
actions
should the nurse anticipate?
a. Emergency pericardiocentesis
b. Stabilization of the chest wall with tape
c. Administration of an inhaled bronchodilator
d. Insertion of a chest tube with a chest drainage system
ANS: D
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. The other
therapies
would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the
patient's clinical manifestations are not consistent with these problems.
A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion
related to cerebral tissue swelling. Which of the following nursing interventions should be
included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANS: A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up
position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure,
which increases ICP. Because the stimulation associated with nursing interventions
increases
ICP, clustering interventions will progressively elevate ICP. Coughing increases
intrathoracic
pressure and ICP
The nurse is caring for a patient with a head injury who has clear nasal drainage. Which of
the
following actions should the nurse take?
a. Have the patient blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal after a head injury.
,NUR 417 Nursing Care of the Adult II
d. Obtain a specimen of the fluid to send for culture and sensitivity
ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal
fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from
the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing
the nose is avoided to prevent CSF leakage.
A patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which of the following actions should the nurse plan to take?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANS: D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma
and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or
highdose barbiturate therapy may be needed, but these will not be of benefit unless the
hematoma
is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not
necessary
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the
following findings should the nurse expect to observe?
a. Judgement changes
b. Expressive aphasia
c. Right-sided weakness
d. Difficulty swallowing
ANS: A
The frontal lobes control intellectual activities such as judgement. Speech is controlled in
the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour.
Swallowing is controlled by the brain stem.
Which of the following statements by a patient who is being discharged from the
emergency department (ED) after a head injury indicates a need for intervention by the
nurse?
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go to bed."
, NUR 417 Nursing Care of the Adult II
c. "I do not even remember being in an accident."
d. "I can take acetaminophen for my headache."
ANS: B Following a head injury, the patient should avoid operating heavy machinery.
Retrograde amnesia is common after a concussion. The patient can take acetaminophen for
headache and should return if symptoms of increased intracranial pressure such as
dizziness or nausea occur
The nurse is caring for a patient who is disoriented and anxious as result of increased
intracranial pressure. Which of the following nursing actions should be included in the plan
of
care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input
ANS: A
Patients with disorientation as result of increased ICP will be calmed by the presence of
someone familiar at the bedside. Restraints should be avoided because they increase
agitation
and anxiety. The patient requires frequent assessment for complications; the use of touch
and a
soothing voice will decrease anxiety for most patients. The patient will have photophobia,
so
the light should be dim.
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial
pressure
(ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP=
MAPICP), below the normal of 70-100 mm Hg and approaching the level of ischemia and
neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral
perfusion.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure. Adjustments in the
head
NUR 417 FINAL EXAM LATEST-
NURSING CARE OF THE ADULT II 2026
COMPLETE QUESTION AND ANSWER
(REAL EXAM)
The health care provider inserts a chest tube in a patient with a hemo-pneumothorax.
When
monitoring the patient after the chest tube placement, which of the following findings is of
greatest concern?
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
ANS: B
The large amount of blood may indicate that the patient is in danger of developing
hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care
provider. A large air leak would be expected immediately after chest tube placement for
pneumothorax. 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.
The nurse is caring for a patient who has a steering wheel injury as a result of an
automobile
accident. Which of the following findings should be of most concern to the nurse during the
initial assessment?
a. Paradoxical chest movement
b. The complaint of chest wall pain
c. A heart rate of 110 beats/minute
d. A large bruised area on the chest
ANS: A
Paradoxical chest movement indicates that the patient may have flail chest, which can
severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a
slightly elevated pulse rate, and chest bruising all require further assessment or
intervention,
but the priority concern is poor gas exchange.
,NUR 417 Nursing Care of the Adult II
The nurse is assessing a patient who has just arrived after an automobile accident and the
nurse notes that the breath sounds are absent on the right side. Which of the following
actions
should the nurse anticipate?
a. Emergency pericardiocentesis
b. Stabilization of the chest wall with tape
c. Administration of an inhaled bronchodilator
d. Insertion of a chest tube with a chest drainage system
ANS: D
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. The other
therapies
would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the
patient's clinical manifestations are not consistent with these problems.
A patient who is unconscious has a nursing diagnosis of ineffective cerebral tissue
perfusion
related to cerebral tissue swelling. Which of the following nursing interventions should be
included in the plan of care?
a. Keep the head of the bed elevated to 30 degrees.
b. Position the patient with the knees and hips flexed.
c. Encourage coughing and deep breathing to improve oxygenation.
d. Cluster nursing interventions to provide uninterrupted rest periods.
ANS: A
The patient with increased intracranial pressure (ICP) should be maintained in the head-up
position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure,
which increases ICP. Because the stimulation associated with nursing interventions
increases
ICP, clustering interventions will progressively elevate ICP. Coughing increases
intrathoracic
pressure and ICP
The nurse is caring for a patient with a head injury who has clear nasal drainage. Which of
the
following actions should the nurse take?
a. Have the patient blow the nose.
b. Check the nasal drainage for glucose.
c. Assure the patient that rhinorrhea is normal after a head injury.
,NUR 417 Nursing Care of the Adult II
d. Obtain a specimen of the fluid to send for culture and sensitivity
ANS: B
Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal
fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from
the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing
the nose is avoided to prevent CSF leakage.
A patient who is suspected of having an epidural hematoma is admitted to the emergency
department. Which of the following actions should the nurse plan to take?
a. Administer IV furosemide.
b. Initiate high-dose barbiturate therapy.
c. Type and crossmatch for blood transfusion.
d. Prepare the patient for immediate craniotomy.
ANS: D
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma
and
prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or
highdose barbiturate therapy may be needed, but these will not be of benefit unless the
hematoma
is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not
necessary
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the
following findings should the nurse expect to observe?
a. Judgement changes
b. Expressive aphasia
c. Right-sided weakness
d. Difficulty swallowing
ANS: A
The frontal lobes control intellectual activities such as judgement. Speech is controlled in
the
parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour.
Swallowing is controlled by the brain stem.
Which of the following statements by a patient who is being discharged from the
emergency department (ED) after a head injury indicates a need for intervention by the
nurse?
a. "I will return if I feel dizzy or nauseated."
b. "I am going to drive home and go to bed."
, NUR 417 Nursing Care of the Adult II
c. "I do not even remember being in an accident."
d. "I can take acetaminophen for my headache."
ANS: B Following a head injury, the patient should avoid operating heavy machinery.
Retrograde amnesia is common after a concussion. The patient can take acetaminophen for
headache and should return if symptoms of increased intracranial pressure such as
dizziness or nausea occur
The nurse is caring for a patient who is disoriented and anxious as result of increased
intracranial pressure. Which of the following nursing actions should be included in the plan
of
care?
a. Encourage family members to remain at the bedside.
b. Apply soft restraints to protect the patient from injury.
c. Keep the room well lighted to improve patient orientation.
d. Minimize contact with the patient to decrease sensory input
ANS: A
Patients with disorientation as result of increased ICP will be calmed by the presence of
someone familiar at the bedside. Restraints should be avoided because they increase
agitation
and anxiety. The patient requires frequent assessment for complications; the use of touch
and a
soothing voice will decrease anxiety for most patients. The patient will have photophobia,
so
the light should be dim.
The nurse is caring for a patient who has a BP of 108/51 mm Hg and an intracranial
pressure
(ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
a. Elevate the head of the patient's bed to 60 degrees.
b. Document the BP and ICP in the patient's record.
c. Report the BP and ICP to the health care provider.
d. Continue to monitor the patient's vital signs and ICP.
ANS: C
The patient's cerebral perfusion pressure is 56 mm Hg (using the calculation CPP=
MAPICP), below the normal of 70-100 mm Hg and approaching the level of ischemia and
neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral
perfusion.
Immediate changes in the patient's therapy such as fluid infusion or vasopressor
administration are needed to improve the cerebral perfusion pressure. Adjustments in the
head
