NUR 417 Exam 3 | Nursing Practice Questions & Verified Answers
A patient describes his involvement in a situation that the Report the suspected abuse to the appropriate agency. Correct
nurse suspects demonstrates the sexual abuse of a child. The nurse is legally obligated to report suspected and actual sexual abuse of
What is the nurse's initial response? 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
A. Verify that the event actually occurred. concern is for the child, even if that means compromising confidentiality.
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
The nurse caring for an older adult suspects elder abuse. C. The nurse is a mandatory reporter of elder abuse and should notify the
Which action is appropriate? authorities of suspected elder abuse.The nurse does not need proof of abuse
A. Collect proof of abuse before notifying the authorities. before calling the authorities.The nurse should not confront the caretakers if elder
B. Confront the caretakers about the suspicion of abuse. abuse is suspected.The nurse does not need permission from the elder before
C. Notify the authorities of the suspected elder abuse. calling the authorities.
D. Report the abuse if the older adult gives permission.
You are working with a child and suspect physical Answer: B - The nurse should report her suspicions to the local authorities so they
abuse. What is your primary legal responsibility? can investigate. The law makes it mandatory to report any suspected child abuse.
A. Document your assessment thoroughly and accurately. All other options are important in dealing with patient and the family, but they would
B. Report the abuse to local authorities. not be the priority of the nurse.
C. Refer the family to support groups.
D. Assist the family in identifying resources and support
systems.
Which action should the nurse plan to prevent aspiration in b. Place a patient with altered consciousness in a side-lying position.
a high-risk patient?
a. Turn and reposition an immobile patient at least every 2 With loss of consciousness, the gag and cough reflexes are depressed, and
hours. aspiration is more likely to occur. The risk for aspiration is decreased when patients
b. Place a patient with altered consciousness in a side- with a decreased level of consciousness are placed in a side-lying or upright
lying position. position.
c. Insert a nasogastric tube for feeding a patient with high
calorie needs.
d. Monitor respiratory symptoms in a patient who is
immunosuppressed.
An occupational health nurse works at a manufacturing c. Require the use of protective equipment.
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.
The nurse monitors a patient in the emergency department b. 400 mL of blood in the collection chamber
after chest tube placement for a hemopneumothorax. The
nurse is most concerned if which assessment finding is The large amount of blood may indicate that the patient is in danger of developing
observed? hypovolemic shock. An air leak would be expected immediately after chest tube
a. A large air leak in the water-seal chamber placement for a pneumothorax
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
A patient experiences a chest wall contusion as a result of a. Paradoxical chest movement
being struck in the chest with a baseball bat. The
emergency department nurse would be most concerned if Paradoxical chest movement indicates that the patient may have flail chest, which
which finding is observed during the initial assessment? can severely compromise gas exchange and can rapidly lead to hypoxemia. When
a. Paradoxical chest movement c. Heart rate of 110 a person has a flail chest, the nurse should stabilize the chest with positive pressure
beats/minute and call a surgeon for surgery.
b. Complaint of chest wall pain d. Large bruised area on
the chest
, NUR 417 Exam 3 | Nursing Practice Questions & Verified Answers
When assessing a patient who has just arrived after an d. Chest tube connected to suction
automobile accident, the emergency department nurse
notes tachycardia and absent breath sounds over the The patient's history and absent breath sounds suggest a right-sided
right lung. For which intervention will the nurse prepare the pneumothorax or hemothorax, which will require treatment with a chest tube and
patient? drainage to suction.
a. Emergency pericardiocentesis
c. Bronchodilator administration
b. Stabilization of the chest wall
d. Chest tube connected to suction
A patient who has a right-sided chest tube after a b. Continue to monitor the collection device.
thoracotomy has continuous bubbling in the suction-control
chamber of the collection device. Which action by the Continuous bubbling is expected in the suction-control chamber and indicates that
nurse is appropriate? the suction-control chamber is connected to suction.
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.
The nurse provides preoperative instruction for a patient c. Frequent use of an incentive spirometer
scheduled for a left pneumonectomy. Which information
should the nurse include about the patient's postoperative Frequent deep breathing and coughing are needed after chest surgery to prevent
care? atelectasis.
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
A patient with a possible pulmonary embolism complains of d. Elevate the head of the bed to a semi-Fowler's position.
chest pain and difficulty breathing. The nurse finds a heart
rate of 142 beats/min, blood pressure of 100/60 mm Hg, The patient has symptoms consistent with a pulmonary embolism (PE). Elevating
and respirations of 42 breaths/min. Which action should the head of the bed will improve ventilation and gas exchange. The other actions
the nurse take first? can be accomplished after the head is elevated (and O2 is started). A spiral CT may
a. Administer anticoagulant drug therapy. be ordered by the health care provider to identify PE. Anticoagulants may be
b. Notify the patient's health care provider. ordered after confirmation of the diagnosis of PE.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position.
A patient is admitted to the emergency department with an d. Tape a nonporous dressing on three sides over the wound.
open stab wound to the left chest. What action should the
nurse take? The dressing taped on three sides will allow air to escape when intrapleural
a. Keep the head of the patient's bed positioned flat. pressure increases during expiration, but it will prevent air from moving into the
b. Cover the wound tightly with an occlusive dressing. pleural space during inspiration
c. Position the patient so that the left chest is dependent.
d. Tape a nonporous dressing on three sides over the
wound.
An experienced nurse instructs a new nurse about how to b. Placing the patient on droplet precautions in a private hospital room
care for a patient with dyspnea caused by a pulmonary
fungal infection. Which action by the new nurse indicates a Fungal infections are not transmitted from person to person. Therefore no isolation
need for further teaching? procedures are necessary.
a. Listening to the patient's lung sounds several times
during the shift
b. Placing the patient on droplet precautions in a private
hospital room
c. Monitoring patient serology results to identify the
infecting organism
d. Increasing the O2 flow rate to keep the O2 saturation
over 90%
The nurse provides discharge teaching for a patient who d. "I will use the incentive spirometer every hour or two during the day."
has two fractured ribs from an automobile accident. Which
statement, if made by the patient, would indicate that
teaching has been effective?
a. "I am going to buy a rib binder to wear during the day."
b. "I can take shallow breaths to prevent my chest from
hurting."
c. "I should plan on taking the pain pills only at bedtime so
I can sleep."
d. "I will use the incentive spirometer every hour or two
during the day."
, NUR 417 Exam 3 | Nursing Practice Questions & Verified Answers
The nurse is caring for a patient who has a right-sided a. Document the amount of drainage every 8 hours.
chest tube after a right lower lobectomy. Which nursing
action can the nurse delegate to the unlicensed assistive
personnel (UAP)?
a. Document the amount of drainage every 8 hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.
After change-of-shift report, which patient should the nurse d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter
assess first? insertion
a. A 72-yr-old with cor pulmonale who has 4+ bilateral
edema in his legs and feet The patient's history and symptoms suggest possible tension pneumothorax, a
b. A 28-yr-old with a history of a lung transplant and a medical emergency. The other patients also require assessment as soon as
temperature of 101° F (38.3° possible, but tension pneumothorax will require immediate treatment to avoid death
C) from inadequate cardiac output or hypoxemia.
c. A 40-yr-old with a pleural effusion who is complaining of
severe stabbing chest
pain
d. A 64-yr-old with lung cancer and tracheal deviation after
subclavian catheter
insertion
The nurse notes new onset confusion in an older patient A, B, D, C
who is normally alert and oriented. In which order should
the nurse take the following actions? (Put a comma and a a. Obtain the O2 saturation.
space between each answer choice [A, B, C, D].) b. Check the patient's pulse rate.
a. Obtain the O2 saturation. d. Notify the health care provider.
b. Check the patient's pulse rate. c. Document the change in status.
c. Document the change in status.
d. Notify the health care provider.
A patient with a gunshot wound to the right side of the Cover the chest wound with a nonporous dressing taped on three sides.
chest arrives in the emergency department exhibiting
severe shortness of breath with decreased breath sounds
on the right side of the chest. Which action should the
nurse take immediately?
Cover the chest wound with a nonporous dressing taped
on three sides.
Pack the chest wound with sterile saline soaked gauze
and tape securely.
Stabilize the chest wall with tape and initiate positive
pressure ventilation.
Apply a pressure dressing over the wound to prevent
excessive loss of blood.
The nurse is caring for a patient with an alteration in airway A, C, E,
clearance. What nursing actions would be a priority to
promote airway clearance (select all that apply.)? a. Maintain adequate fluid intake.
Select all that apply. c. Splint the chest when coughing.
e. Instruct patient to cough at end of exhalation.
a. Maintain adequate fluid intake.
b. Maintain a 30-degree elevation.
c. Splint the chest when coughing.
d. Maintain a semi-Fowler's position.
e. Instruct patient to cough at end of exhalation.
A patient describes his involvement in a situation that the Report the suspected abuse to the appropriate agency. Correct
nurse suspects demonstrates the sexual abuse of a child. The nurse is legally obligated to report suspected and actual sexual abuse of
What is the nurse's initial response? 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
A. Verify that the event actually occurred. concern is for the child, even if that means compromising confidentiality.
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
The nurse caring for an older adult suspects elder abuse. C. The nurse is a mandatory reporter of elder abuse and should notify the
Which action is appropriate? authorities of suspected elder abuse.The nurse does not need proof of abuse
A. Collect proof of abuse before notifying the authorities. before calling the authorities.The nurse should not confront the caretakers if elder
B. Confront the caretakers about the suspicion of abuse. abuse is suspected.The nurse does not need permission from the elder before
C. Notify the authorities of the suspected elder abuse. calling the authorities.
D. Report the abuse if the older adult gives permission.
You are working with a child and suspect physical Answer: B - The nurse should report her suspicions to the local authorities so they
abuse. What is your primary legal responsibility? can investigate. The law makes it mandatory to report any suspected child abuse.
A. Document your assessment thoroughly and accurately. All other options are important in dealing with patient and the family, but they would
B. Report the abuse to local authorities. not be the priority of the nurse.
C. Refer the family to support groups.
D. Assist the family in identifying resources and support
systems.
Which action should the nurse plan to prevent aspiration in b. Place a patient with altered consciousness in a side-lying position.
a high-risk patient?
a. Turn and reposition an immobile patient at least every 2 With loss of consciousness, the gag and cough reflexes are depressed, and
hours. aspiration is more likely to occur. The risk for aspiration is decreased when patients
b. Place a patient with altered consciousness in a side- with a decreased level of consciousness are placed in a side-lying or upright
lying position. position.
c. Insert a nasogastric tube for feeding a patient with high
calorie needs.
d. Monitor respiratory symptoms in a patient who is
immunosuppressed.
An occupational health nurse works at a manufacturing c. Require the use of protective equipment.
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.
The nurse monitors a patient in the emergency department b. 400 mL of blood in the collection chamber
after chest tube placement for a hemopneumothorax. The
nurse is most concerned if which assessment finding is The large amount of blood may indicate that the patient is in danger of developing
observed? hypovolemic shock. An air leak would be expected immediately after chest tube
a. A large air leak in the water-seal chamber placement for a pneumothorax
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
A patient experiences a chest wall contusion as a result of a. Paradoxical chest movement
being struck in the chest with a baseball bat. The
emergency department nurse would be most concerned if Paradoxical chest movement indicates that the patient may have flail chest, which
which finding is observed during the initial assessment? can severely compromise gas exchange and can rapidly lead to hypoxemia. When
a. Paradoxical chest movement c. Heart rate of 110 a person has a flail chest, the nurse should stabilize the chest with positive pressure
beats/minute and call a surgeon for surgery.
b. Complaint of chest wall pain d. Large bruised area on
the chest
, NUR 417 Exam 3 | Nursing Practice Questions & Verified Answers
When assessing a patient who has just arrived after an d. Chest tube connected to suction
automobile accident, the emergency department nurse
notes tachycardia and absent breath sounds over the The patient's history and absent breath sounds suggest a right-sided
right lung. For which intervention will the nurse prepare the pneumothorax or hemothorax, which will require treatment with a chest tube and
patient? drainage to suction.
a. Emergency pericardiocentesis
c. Bronchodilator administration
b. Stabilization of the chest wall
d. Chest tube connected to suction
A patient who has a right-sided chest tube after a b. Continue to monitor the collection device.
thoracotomy has continuous bubbling in the suction-control
chamber of the collection device. Which action by the Continuous bubbling is expected in the suction-control chamber and indicates that
nurse is appropriate? the suction-control chamber is connected to suction.
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.
The nurse provides preoperative instruction for a patient c. Frequent use of an incentive spirometer
scheduled for a left pneumonectomy. Which information
should the nurse include about the patient's postoperative Frequent deep breathing and coughing are needed after chest surgery to prevent
care? atelectasis.
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
A patient with a possible pulmonary embolism complains of d. Elevate the head of the bed to a semi-Fowler's position.
chest pain and difficulty breathing. The nurse finds a heart
rate of 142 beats/min, blood pressure of 100/60 mm Hg, The patient has symptoms consistent with a pulmonary embolism (PE). Elevating
and respirations of 42 breaths/min. Which action should the head of the bed will improve ventilation and gas exchange. The other actions
the nurse take first? can be accomplished after the head is elevated (and O2 is started). A spiral CT may
a. Administer anticoagulant drug therapy. be ordered by the health care provider to identify PE. Anticoagulants may be
b. Notify the patient's health care provider. ordered after confirmation of the diagnosis of PE.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler's position.
A patient is admitted to the emergency department with an d. Tape a nonporous dressing on three sides over the wound.
open stab wound to the left chest. What action should the
nurse take? The dressing taped on three sides will allow air to escape when intrapleural
a. Keep the head of the patient's bed positioned flat. pressure increases during expiration, but it will prevent air from moving into the
b. Cover the wound tightly with an occlusive dressing. pleural space during inspiration
c. Position the patient so that the left chest is dependent.
d. Tape a nonporous dressing on three sides over the
wound.
An experienced nurse instructs a new nurse about how to b. Placing the patient on droplet precautions in a private hospital room
care for a patient with dyspnea caused by a pulmonary
fungal infection. Which action by the new nurse indicates a Fungal infections are not transmitted from person to person. Therefore no isolation
need for further teaching? procedures are necessary.
a. Listening to the patient's lung sounds several times
during the shift
b. Placing the patient on droplet precautions in a private
hospital room
c. Monitoring patient serology results to identify the
infecting organism
d. Increasing the O2 flow rate to keep the O2 saturation
over 90%
The nurse provides discharge teaching for a patient who d. "I will use the incentive spirometer every hour or two during the day."
has two fractured ribs from an automobile accident. Which
statement, if made by the patient, would indicate that
teaching has been effective?
a. "I am going to buy a rib binder to wear during the day."
b. "I can take shallow breaths to prevent my chest from
hurting."
c. "I should plan on taking the pain pills only at bedtime so
I can sleep."
d. "I will use the incentive spirometer every hour or two
during the day."
, NUR 417 Exam 3 | Nursing Practice Questions & Verified Answers
The nurse is caring for a patient who has a right-sided a. Document the amount of drainage every 8 hours.
chest tube after a right lower lobectomy. Which nursing
action can the nurse delegate to the unlicensed assistive
personnel (UAP)?
a. Document the amount of drainage every 8 hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.
After change-of-shift report, which patient should the nurse d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter
assess first? insertion
a. A 72-yr-old with cor pulmonale who has 4+ bilateral
edema in his legs and feet The patient's history and symptoms suggest possible tension pneumothorax, a
b. A 28-yr-old with a history of a lung transplant and a medical emergency. The other patients also require assessment as soon as
temperature of 101° F (38.3° possible, but tension pneumothorax will require immediate treatment to avoid death
C) from inadequate cardiac output or hypoxemia.
c. A 40-yr-old with a pleural effusion who is complaining of
severe stabbing chest
pain
d. A 64-yr-old with lung cancer and tracheal deviation after
subclavian catheter
insertion
The nurse notes new onset confusion in an older patient A, B, D, C
who is normally alert and oriented. In which order should
the nurse take the following actions? (Put a comma and a a. Obtain the O2 saturation.
space between each answer choice [A, B, C, D].) b. Check the patient's pulse rate.
a. Obtain the O2 saturation. d. Notify the health care provider.
b. Check the patient's pulse rate. c. Document the change in status.
c. Document the change in status.
d. Notify the health care provider.
A patient with a gunshot wound to the right side of the Cover the chest wound with a nonporous dressing taped on three sides.
chest arrives in the emergency department exhibiting
severe shortness of breath with decreased breath sounds
on the right side of the chest. Which action should the
nurse take immediately?
Cover the chest wound with a nonporous dressing taped
on three sides.
Pack the chest wound with sterile saline soaked gauze
and tape securely.
Stabilize the chest wall with tape and initiate positive
pressure ventilation.
Apply a pressure dressing over the wound to prevent
excessive loss of blood.
The nurse is caring for a patient with an alteration in airway A, C, E,
clearance. What nursing actions would be a priority to
promote airway clearance (select all that apply.)? a. Maintain adequate fluid intake.
Select all that apply. c. Splint the chest when coughing.
e. Instruct patient to cough at end of exhalation.
a. Maintain adequate fluid intake.
b. Maintain a 30-degree elevation.
c. Splint the chest when coughing.
d. Maintain a semi-Fowler's position.
e. Instruct patient to cough at end of exhalation.
