CHII EXAM 4 (MSK,
HEMATOLOGY, ER &
REPRODUCTIVE) QUESTIONS
AND ANSWERS (LATEST UPDATE )
A client who has a plaster leg splint reports a painful pressure sensa3on under
the elas3c wrap that is holding the splint in place. What is the nurse's best
ini3al ac3on?
A. Remove the splint to reduce skin pressure.
B. Perform a neurovascular assessment.
C. Report the client's concern to the primary health care provider.
D. Inspect the skin under the elas3c bandage.
B. Perform a neurovascular assessment
The nurse is caring for an older adult client with heat exhaus3on. What
assessment finding indicates to the nurse that the client may need
hospitaliza3on?
A. Alert and oriented
b. Reports nausea and weakness
c. Con3nues to sweat while being cooled
d. Mucous membranes are dry and s3cky.
D.
The community nurse is educa3ng a client about frostbite preven3on. Which
factors will the nurse teach that are risk factors for developing frostbite? (select
all that apply.)
A. Dehydra3on
,b. Smoking history
c. Previous frostbite
d. Excessive fa3gue
e. Smoking
f. Wearing wool socks
g. History of diabetes
A,b,c,d,e,g (wearing wool socks is a good preven3on against frostbite, the rest
are risk factors)
AOer a mass casualty event, the nurse is triaging clients in the field. Which
client is correctly classified?
A. 38-year-old with an open femur fracture: black tag
b. 42-year-old with mul3ple abrasions and contusions: yellow tag
c. 54-year-old with third-degree burns over 90% of the body: green tag
d. 61-year-old who is having difficulty breathing and wheezing: red tag
D. 61 y/o w/ sob = red
Which assessment finding does the nurse interpret as demonstra3ng a client's
fluid resuscita3on adequacy?
A. Increased skin turgor
b. Decreased pulse pressure
c. Decreased core body temperature
d. Decreased urine specific gravity
D. Decreased urine specific gravity (indicates more water in the urine and skin
turgor is not as accurate)
Which nursing interven3on(s) decrease(s) the risk for cross-contamina3on in
the client with a severe burn injury? (select all that apply.)
,A. Place client in isola3on.
B. Encourage mul3ple visitors to support client.
C. Ensure that no plants or flowers are in the client's room.
D. Teach family members not to bring fresh fruits and vegetables to the client.
E. Change gloves aOer cleaning and dressing of one wound area, before
cleaning and dressing another.
A,c,d (e decreases the risk of auto-contamina3on not cross-contamina3on)
The nurse is encouraging range-of-mo3on exercises for the client, who states,
"this hurts terribly; i don't want to do this." iden3fy the appropriate nursing
response(s). (select all that apply.)
A. "you have to do the exercises to get well."
b. "range-of-mo3on helps promote mobility."
c. "just visualize a beach to get your mind off of the pain."
d. "let me check when you were last given pain medica3on."
e. "what techniques for pain management have you used in the past that were
helpful?"
f. "the health care provider has ordered these exercises, and it is important that
you do them as instructed."
B,d,e
Which signs and symptoms does the nurse expect to find in clients with any
type of anemia? (select all that apply.)
A. Exercise intolerance
b. Fa3gue
c. Glossi3s
d. Jaundice
e. Pain
f. Microcy3c red blood cells
, g. Paresthesias of the hands and feet
h. Tachycardia
A,b,e,h (not microcy3c rbc, but sickled)
A young black woman who has sickle cell disease (scd) comes to the emergency
department with severe joint and back pain, a cough, a temperature of 102.2°f
(39°c), and shortness of breath. She appears anxious and states "i have never
felt this way before." the health care provider prescribes 3 mg of morphine iv
and a stat chest x-ray. What addi3onal assessment data are most important to
obtain?
A. Blood glucose
b. Any recent infec3ons
c. Any fa3gue related to exercise
d. Pulse oximetry and respiratory assessment
D. Pulse o2 and respiratory assessment (pts with acute respiratory distress is a
major cause of death in sickle cell disease)
A young black woman who has sickle cell disease (scd) comes to the emergency
department with severe joint and back pain, a cough, a temperature of 102.2°f
(39°c), and shortness of breath. She appears anxious and states "i have never
felt this way before." the health care provider prescribes 3 mg of morphine iv
and a stat chest x-ray. Should oxygen be started even though it has not yet
been prescribed? Why or why not?
A. Yes, o2 will help with sickle cell disease regardless
b. Yes, o2 will decrease her pain
c. No, o2 is a medica3on and needs provider orders
d. No, she will be fine.
A. Yes (o2 is a staple in managing scd)
HEMATOLOGY, ER &
REPRODUCTIVE) QUESTIONS
AND ANSWERS (LATEST UPDATE )
A client who has a plaster leg splint reports a painful pressure sensa3on under
the elas3c wrap that is holding the splint in place. What is the nurse's best
ini3al ac3on?
A. Remove the splint to reduce skin pressure.
B. Perform a neurovascular assessment.
C. Report the client's concern to the primary health care provider.
D. Inspect the skin under the elas3c bandage.
B. Perform a neurovascular assessment
The nurse is caring for an older adult client with heat exhaus3on. What
assessment finding indicates to the nurse that the client may need
hospitaliza3on?
A. Alert and oriented
b. Reports nausea and weakness
c. Con3nues to sweat while being cooled
d. Mucous membranes are dry and s3cky.
D.
The community nurse is educa3ng a client about frostbite preven3on. Which
factors will the nurse teach that are risk factors for developing frostbite? (select
all that apply.)
A. Dehydra3on
,b. Smoking history
c. Previous frostbite
d. Excessive fa3gue
e. Smoking
f. Wearing wool socks
g. History of diabetes
A,b,c,d,e,g (wearing wool socks is a good preven3on against frostbite, the rest
are risk factors)
AOer a mass casualty event, the nurse is triaging clients in the field. Which
client is correctly classified?
A. 38-year-old with an open femur fracture: black tag
b. 42-year-old with mul3ple abrasions and contusions: yellow tag
c. 54-year-old with third-degree burns over 90% of the body: green tag
d. 61-year-old who is having difficulty breathing and wheezing: red tag
D. 61 y/o w/ sob = red
Which assessment finding does the nurse interpret as demonstra3ng a client's
fluid resuscita3on adequacy?
A. Increased skin turgor
b. Decreased pulse pressure
c. Decreased core body temperature
d. Decreased urine specific gravity
D. Decreased urine specific gravity (indicates more water in the urine and skin
turgor is not as accurate)
Which nursing interven3on(s) decrease(s) the risk for cross-contamina3on in
the client with a severe burn injury? (select all that apply.)
,A. Place client in isola3on.
B. Encourage mul3ple visitors to support client.
C. Ensure that no plants or flowers are in the client's room.
D. Teach family members not to bring fresh fruits and vegetables to the client.
E. Change gloves aOer cleaning and dressing of one wound area, before
cleaning and dressing another.
A,c,d (e decreases the risk of auto-contamina3on not cross-contamina3on)
The nurse is encouraging range-of-mo3on exercises for the client, who states,
"this hurts terribly; i don't want to do this." iden3fy the appropriate nursing
response(s). (select all that apply.)
A. "you have to do the exercises to get well."
b. "range-of-mo3on helps promote mobility."
c. "just visualize a beach to get your mind off of the pain."
d. "let me check when you were last given pain medica3on."
e. "what techniques for pain management have you used in the past that were
helpful?"
f. "the health care provider has ordered these exercises, and it is important that
you do them as instructed."
B,d,e
Which signs and symptoms does the nurse expect to find in clients with any
type of anemia? (select all that apply.)
A. Exercise intolerance
b. Fa3gue
c. Glossi3s
d. Jaundice
e. Pain
f. Microcy3c red blood cells
, g. Paresthesias of the hands and feet
h. Tachycardia
A,b,e,h (not microcy3c rbc, but sickled)
A young black woman who has sickle cell disease (scd) comes to the emergency
department with severe joint and back pain, a cough, a temperature of 102.2°f
(39°c), and shortness of breath. She appears anxious and states "i have never
felt this way before." the health care provider prescribes 3 mg of morphine iv
and a stat chest x-ray. What addi3onal assessment data are most important to
obtain?
A. Blood glucose
b. Any recent infec3ons
c. Any fa3gue related to exercise
d. Pulse oximetry and respiratory assessment
D. Pulse o2 and respiratory assessment (pts with acute respiratory distress is a
major cause of death in sickle cell disease)
A young black woman who has sickle cell disease (scd) comes to the emergency
department with severe joint and back pain, a cough, a temperature of 102.2°f
(39°c), and shortness of breath. She appears anxious and states "i have never
felt this way before." the health care provider prescribes 3 mg of morphine iv
and a stat chest x-ray. Should oxygen be started even though it has not yet
been prescribed? Why or why not?
A. Yes, o2 will help with sickle cell disease regardless
b. Yes, o2 will decrease her pain
c. No, o2 is a medica3on and needs provider orders
d. No, she will be fine.
A. Yes (o2 is a staple in managing scd)
