NUR417 / NUR 417 EXAM 3 Care of Adult II | Test Questions and Answers | Latest Update 2026/2027 | Graded A+ | Verified (Concordia, St. Paul)

NUR417 / NUR 417 EXAM 3 Care of Adult II | Test Questions and Answers | Latest Update 2026/2027 | Graded A+ | Verified (Concordia, St. Paul) 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. ANSWER 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. 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. Answer 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 Answer 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 Answer 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. 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. ANSWER 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. 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 Answer 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 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 Answer 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. A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? a. Keep the head of the patient's bed positioned flat. b. Cover the wound tightly with an occlusive dressing. c. Position the patient so that the left chest is dependent. d. Tape a nonporous dressing on three sides over the wound. Answer d. Tape a nonporous dressing on three sides over the wound. The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? 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% Answer b. Placing the patient on droplet precautions in a private hospital room Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The nurse provides discharge teaching for a patient who 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." Answer d. "I will use the incentive spirometer every hour or two during the day." The nurse is caring for a patient who has a right-sided 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. a. Document the amount of drainage every 8 hours. After change-of-shift report, which patient should the nurse assess first? a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C) 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 d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia. The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.