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Nurs 480 Exam 1 Newest Actual Exam Preparation
With Complete Questions And Correct Answers With
Rationales ||Verified Exam!!!| Already Graded
A+||Newest Exam Version!!!
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. - Answer-
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
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is needed before notifying the health care provider,
offering reassurance, or administration of morphine
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. - Answer-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
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or atelectasis. The vibration is increased in conditions
such as pneumonia, lung tumors, thick bronchial
secretions, and pleural effusion. Turning, coughing, and
deep breathing is an appropriate intervention for
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 chest).The
anterior of the chest is more difficult to palpate for fremitus
because of the presence of large muscles and breast
tissue.
The nurse monitors a patient 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-ANS: B
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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.
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.
Nurs 480 Exam 1 Newest Actual Exam Preparation
With Complete Questions And Correct Answers With
Rationales ||Verified Exam!!!| Already Graded
A+||Newest Exam Version!!!
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. - Answer-
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
,2|Page
is needed before notifying the health care provider,
offering reassurance, or administration of morphine
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. - Answer-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
,3|Page
or atelectasis. The vibration is increased in conditions
such as pneumonia, lung tumors, thick bronchial
secretions, and pleural effusion. Turning, coughing, and
deep breathing is an appropriate intervention for
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 chest).The
anterior of the chest is more difficult to palpate for fremitus
because of the presence of large muscles and breast
tissue.
The nurse monitors a patient 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-ANS: B
, 4|Page
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.
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.
