NUR417 NUR 417 EXAM 3

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

• / 4

The nurse caring for an older adult suspects elder abuse. Which action is appropriate?

• Collect proof of abuse before notifying the authorities.
• Confront the caretakers about the suspicion of abuse.
• Notify the authorities of the suspected elder abuse.
• Report the abuse if the older adult gives permission.

ANSWER

• 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?

• Document your assessment thoroughly and accurately.
• Report the abuse to local authorities.
• Refer the family to support groups.
• 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?

• Turn and reposition an immobile patient at least every 2 hours.
• Place a patient with altered consciousness in a side-lying position.
• Insert a nasogastric tube for feeding a patient with high calorie 2 / 4

needs.

• Monitor respiratory symptoms in a patient who is

immunosuppressed.

ANSWER

• 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?

• Treat workers with pulmonary fibrosis.
• Teach about symptoms of lung disease.
• Require the use of protective equipment.
• Monitor workers for coughing and wheezing.

Answer

• 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 large air leak in the water-seal chamber
• 400 mL of blood in the collection chamber
• Complaint of pain with each deep inspiration
• Subcutaneous emphysema at the insertion site

Answer

• 400 mL of blood in the collection chamber
• / 4

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?

• Paradoxical chest movement c. Heart rate of 110 beats/minute
• Complaint of chest wall pain d. Large bruised area on the chest

Answer

• 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?

• Emergency pericardiocentesis
• Bronchodilator administration
• Stabilization of the chest wall
• Chest tube connected to suction

Answer

• 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.

• / 4