NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
ACCURATE
1. 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.: 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, ottering reassurance, or administration of morphine
2. 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.: 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 ettusion. Turning, coughing, and deep breathing is an
appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is
, NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
ACCURATE
decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of
the chest is more diflcult to palpate for fremitus because of the presence of large muscles and breast
tissue.
, NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
ACCURATE
3. The nurse monitors a patient after chest tube placement for a
hemopneu- mothorax. The nurse is most concerned if which
assessment finding is ob- served?
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.
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.
4. 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.
d. Adjust the dial on the wall regulator to decrease suction.: ANS: C
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control
chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no
evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction
, NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
pressure. The amount of suction applied isACCURATE
regulated by the amount of water in this chamber and not
by the amount of suction applied to the system.
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
ACCURATE
1. 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.: 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, ottering reassurance, or administration of morphine
2. 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.: 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 ettusion. Turning, coughing, and deep breathing is an
appropriate intervention for atelectasis, but the nurse needs to first assess breath sounds. Fremitus is
, NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
ACCURATE
decreased if the hand is farther from the lung or the lung is hyperinflated (barrel chest).The anterior of
the chest is more diflcult to palpate for fremitus because of the presence of large muscles and breast
tissue.
, NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
ACCURATE
3. The nurse monitors a patient after chest tube placement for a
hemopneu- mothorax. The nurse is most concerned if which
assessment finding is ob- served?
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.
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.
4. 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.
d. Adjust the dial on the wall regulator to decrease suction.: ANS: C
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control
chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no
evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction
, NURS 480 EXAM 1 REVIEW QUESTIONS WITH
RESOLVED MULTIPLE CHOICE SOLUTIONS.100%
pressure. The amount of suction applied isACCURATE
regulated by the amount of water in this chamber and not
by the amount of suction applied to the system.
