4/11/25, 8:43
PM
NURS 480 EXAM 1 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
1
Terms in this set (43)
Which action should the nurse take ANS: C
first when a patient complains of acute
chest pain and dyspnea soon after The initial action should be to assess the patient further because the history and
insertion of a centrally inserted IV symptoms are consistent with several possible complications of central line
catheter? insertion, including embolism and pneumothorax. The other actions may be
appropriate, but further assessment of the patient is needed before notifying the
a.Notify the health care provider. health care provider, offering reassurance, or administration of morphine
b.Offer reassurance to the patient.
c.Auscultate the patients breath sounds.
d. Give the prescribed PRN morphine
sulfate IV.
The nurse palpates the posterior chest ANS: D
while the patient says 99 and notes
absent fremitus. Which action should the To assess for tactile fremitus, the nurse should use the palms of the hands to
nurse take next? 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
a.Palpate the anterior chest and the presence or absence of breath sounds. Absent fremitus may be noted with
observe for barrel chest. pneumothorax or atelectasis. The vibration is increased in conditions such as
pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.
b. Encourage the patient to turn, Turning, coughing, and deep breathing is an appropriate intervention for
cough, and deep breathe. atelectasis, but the nurse needs to first assess breath sounds. Fremitus is
decreased if the hand is farther from the lung or the lung is hyperinflated (barrel
c. Review the chest x-ray report chest).The anterior of the chest is more difficult to palpate for fremitus
for evidence of pneumonia. because of the presence of large
muscles and breast tissue.
d.Auscultate anterior and posterior
breath sounds bilaterally.
1/17
,4/11/25, 8:43
PM
The nurse monitors a patient after chest ANS: B
tube placement for a
hemopneumothorax. The nurse is most The large amount of blood may indicate that the patient is in danger of
concerned if which assessment finding is developing hypovolemic shock. An air leak would be expected immediately after
observed? 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
a.A large air leak in the water- but is not as urgent a concern as the possibility of continued hemorrhage.
seal chamber 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
b. 400 mL of blood in the reabsorbed.
collection chamber
c. Complaint of pain with each deep
inspiration
d. Subcutaneous emphysema at the
insertion site
A patient who has a right-sided chest ANS: C
tube following a thoracotomy has
continuous bubbling in the Continuous bubbling is expected in the suction-control chamber and indicates
suction- that the suction-control chamber is connected to suction. An air leak would be
control chamber of the collection device. detected in the water-seal chamber. There is no evidence of
Which action by the nurse is most pneumothorax.
appropriate? Increasing or decreasing the vacuum source will not adjust the suction pressure.
The amount of suction applied is regulated by the amount of water in this
a.Document the presence of a large air chamber and not by the amount of suction applied to the system.
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.
The nurse cares for a patient who has just ANS: A
had a thoracentesis. Which assessment
information obtained by the nurse is a Oxygen saturation would be expected to improve after a thoracentesis. A
priority to communicate to the health saturation of 88% indicates that a complication such as pneumothorax may be
care provider? occurring. The other assessment data also indicate a need for ongoing
assessment or intervention, but the low oxygen saturation is the priority.
a.Oxygen saturation is 88%.
b. Blood pressure is 145/90 mm Hg.
c. Respiratory rate is 22 breaths/minute
when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a
deep breath.
2/17
, 4/11/25, 8:43
PM
A patient is admitted to the emergency ANS: B
department with an open stab wound to
the left chest. What is the first action that The dressing taped on three sides will allow air to escape when intrapleural
the nurse should take? pressure increases during expiration, but it will prevent air from moving into the
pleural space during inspiration. Placing the patient on the left side or
a.Position the patient so that the covering the chest wound with an occlusive dressing will allow trapped air in
left chest is dependent. the pleural
space and cause tension pneumothorax. The head of the bed should be elevated
b.Tape a nonporous dressing on three to 30 to 45 degrees to facilitate breathing.
sides over the chest wound.
c. Cover the sucking chest wound
firmly with an occlusive dressing.
d. Keep the head of the patients bed at
no more than 30 degrees elevation.
A patient returned from a laparoscopic ANS: C
Nissen fundoplication for hiatal hernia 4
hours ago. Which assessment finding is Decreased breath sounds on one side may indicate a pneumothorax, which
most important for the nurse to address requires rapid diagnosis and treatment. The nausea and abdominal pain should
immediately? also be addressed but they are not as high priority as the patients respiratory
status. The patients decreased bowel sounds are expected after surgery and
a.The patient is experiencing intermittent require ongoing monitoring but no other action.
waves of nausea.
b.The patient complains of 7/10 (0 to 10
scale) abdominal pain.
c.The patient has absent breath sounds in
the left anterior chest.
d.The patient has hypoactive bowel
sounds in all four quadrants
A patient with acute respiratory distress ANS: D
syndrome (ARDS) who is intubated and
receiving mechanical ventilation develops Because barotrauma is associated with high airway pressures, the level of PEEP
a right pneumothorax. Which action should be decreased. The other actions will not decrease the risk for
will the nurse anticipate taking next? pneumothorax.
a.Increase the tidal volume
and respiratory rate.
b. Increase the fraction of inspired
oxygen (FIO2).
c. Perform endotracheal suctioning more
frequently.
d. Lower the positive end-expiratory
pressure (PEEP).
When assessing a patient who has just ANS: D
arrived after an automobile accident, the
emergency department nurse notes The patients history and absent breath sounds suggest a right-sided
tachycardia and absent breath sounds pneumothorax or hemothorax, which will require treatment with a chest tube
3/17
PM
NURS 480 EXAM 1 QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED
1
Terms in this set (43)
Which action should the nurse take ANS: C
first when a patient complains of acute
chest pain and dyspnea soon after The initial action should be to assess the patient further because the history and
insertion of a centrally inserted IV symptoms are consistent with several possible complications of central line
catheter? insertion, including embolism and pneumothorax. The other actions may be
appropriate, but further assessment of the patient is needed before notifying the
a.Notify the health care provider. health care provider, offering reassurance, or administration of morphine
b.Offer reassurance to the patient.
c.Auscultate the patients breath sounds.
d. Give the prescribed PRN morphine
sulfate IV.
The nurse palpates the posterior chest ANS: D
while the patient says 99 and notes
absent fremitus. Which action should the To assess for tactile fremitus, the nurse should use the palms of the hands to
nurse take next? 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
a.Palpate the anterior chest and the presence or absence of breath sounds. Absent fremitus may be noted with
observe for barrel chest. pneumothorax or atelectasis. The vibration is increased in conditions such as
pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.
b. Encourage the patient to turn, Turning, coughing, and deep breathing is an appropriate intervention for
cough, and deep breathe. atelectasis, but the nurse needs to first assess breath sounds. Fremitus is
decreased if the hand is farther from the lung or the lung is hyperinflated (barrel
c. Review the chest x-ray report chest).The anterior of the chest is more difficult to palpate for fremitus
for evidence of pneumonia. because of the presence of large
muscles and breast tissue.
d.Auscultate anterior and posterior
breath sounds bilaterally.
1/17
,4/11/25, 8:43
PM
The nurse monitors a patient after chest ANS: B
tube placement for a
hemopneumothorax. The nurse is most The large amount of blood may indicate that the patient is in danger of
concerned if which assessment finding is developing hypovolemic shock. An air leak would be expected immediately after
observed? 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
a.A large air leak in the water- but is not as urgent a concern as the possibility of continued hemorrhage.
seal chamber 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
b. 400 mL of blood in the reabsorbed.
collection chamber
c. Complaint of pain with each deep
inspiration
d. Subcutaneous emphysema at the
insertion site
A patient who has a right-sided chest ANS: C
tube following a thoracotomy has
continuous bubbling in the Continuous bubbling is expected in the suction-control chamber and indicates
suction- that the suction-control chamber is connected to suction. An air leak would be
control chamber of the collection device. detected in the water-seal chamber. There is no evidence of
Which action by the nurse is most pneumothorax.
appropriate? Increasing or decreasing the vacuum source will not adjust the suction pressure.
The amount of suction applied is regulated by the amount of water in this
a.Document the presence of a large air chamber and not by the amount of suction applied to the system.
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.
The nurse cares for a patient who has just ANS: A
had a thoracentesis. Which assessment
information obtained by the nurse is a Oxygen saturation would be expected to improve after a thoracentesis. A
priority to communicate to the health saturation of 88% indicates that a complication such as pneumothorax may be
care provider? occurring. The other assessment data also indicate a need for ongoing
assessment or intervention, but the low oxygen saturation is the priority.
a.Oxygen saturation is 88%.
b. Blood pressure is 145/90 mm Hg.
c. Respiratory rate is 22 breaths/minute
when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a
deep breath.
2/17
, 4/11/25, 8:43
PM
A patient is admitted to the emergency ANS: B
department with an open stab wound to
the left chest. What is the first action that The dressing taped on three sides will allow air to escape when intrapleural
the nurse should take? pressure increases during expiration, but it will prevent air from moving into the
pleural space during inspiration. Placing the patient on the left side or
a.Position the patient so that the covering the chest wound with an occlusive dressing will allow trapped air in
left chest is dependent. the pleural
space and cause tension pneumothorax. The head of the bed should be elevated
b.Tape a nonporous dressing on three to 30 to 45 degrees to facilitate breathing.
sides over the chest wound.
c. Cover the sucking chest wound
firmly with an occlusive dressing.
d. Keep the head of the patients bed at
no more than 30 degrees elevation.
A patient returned from a laparoscopic ANS: C
Nissen fundoplication for hiatal hernia 4
hours ago. Which assessment finding is Decreased breath sounds on one side may indicate a pneumothorax, which
most important for the nurse to address requires rapid diagnosis and treatment. The nausea and abdominal pain should
immediately? also be addressed but they are not as high priority as the patients respiratory
status. The patients decreased bowel sounds are expected after surgery and
a.The patient is experiencing intermittent require ongoing monitoring but no other action.
waves of nausea.
b.The patient complains of 7/10 (0 to 10
scale) abdominal pain.
c.The patient has absent breath sounds in
the left anterior chest.
d.The patient has hypoactive bowel
sounds in all four quadrants
A patient with acute respiratory distress ANS: D
syndrome (ARDS) who is intubated and
receiving mechanical ventilation develops Because barotrauma is associated with high airway pressures, the level of PEEP
a right pneumothorax. Which action should be decreased. The other actions will not decrease the risk for
will the nurse anticipate taking next? pneumothorax.
a.Increase the tidal volume
and respiratory rate.
b. Increase the fraction of inspired
oxygen (FIO2).
c. Perform endotracheal suctioning more
frequently.
d. Lower the positive end-expiratory
pressure (PEEP).
When assessing a patient who has just ANS: D
arrived after an automobile accident, the
emergency department nurse notes The patients history and absent breath sounds suggest a right-sided
tachycardia and absent breath sounds pneumothorax or hemothorax, which will require treatment with a chest tube
3/17
