NUR417 / NUR 417 EXAM 3
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Expert Verified Explanation
➢ Multiple choice (single best answer)
➢ Select All That Apply (SATA)
➢ Fill-in-the-blank
➢ Case Studies/Scenario-Based Questions
,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.
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.
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.
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.
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Expert Verified Explanation
➢ Multiple choice (single best answer)
➢ Select All That Apply (SATA)
➢ Fill-in-the-blank
➢ Case Studies/Scenario-Based Questions
,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.
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.
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.
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.
