CHII Exam 4 Questions Solved 100%
A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is
holding the splint in place. What is the nurse's best initial action?
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 elastic bandage. - Answers b. perform a neurovascular assessment
The nurse is caring for an older adult client with heat exhaustion. What assessment finding indicates to
the nurse that the client may need hospitalization?
a. Alert and oriented
b. Reports nausea and weakness
c. Continues to sweat while being cooled
d. Mucous membranes are dry and sticky. - Answers d.
The community nurse is educating a client about frostbite prevention. Which factors will the nurse teach
that are risk factors for developing frostbite? (Select all that apply.)
a. Dehydration
b. Smoking history
c. Previous frostbite
d. Excessive fatigue
e. Smoking
f. Wearing wool socks
g. History of diabetes - Answers a,b,c,d,e,g (wearing wool socks is a good prevention against frostbite,
the rest are risk factors)
After 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 multiple 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 - Answers d. 61 y/o w/ SOB = Red
Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation
adequacy?
a. Increased skin turgor
b. Decreased pulse pressure
c. Decreased core body temperature
d. Decreased urine specific gravity - Answers d. decreased urine specific gravity (indicates more water in
the urine and skin turgor is not as accurate)
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe
burn injury? (Select all that apply.)
a. Place client in isolation.
b. Encourage multiple 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 after cleaning and dressing of one wound area, before cleaning and dressing another. -
Answers a,c,d (e decreases the risk of auto-contamination not cross-contamination)
The nurse is encouraging range-of-motion exercises for the client, who states, "this hurts terribly; I don't
want to do this." Identify the appropriate nursing response(s). (Select all that apply.)
a. "You have to do the exercises to get well."
b. "Range-of-motion 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 medication."
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." - Answers 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. Fatigue
c. Glossitis
d. Jaundice
e. pain
f. Microcytic red blood cells
g. Paresthesias of the hands and feet
h. Tachycardia - Answers a,b,e,h (not microcytic 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 additional assessment data are most important to obtain?
a. Blood glucose
b. Any recent infections
c. Any fatigue related to exercise
d. Pulse oximetry and respiratory assessment - Answers 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 medication and needs provider orders
, d. No, she will be fine. - Answers a. Yes (O2 is a staple in managing SCD)
What additional assessment data will the nurse collect from an older Euro-American (white) woman to
determine the client's risk for osteoporosis? (Select all that apply.)
a. Tobacco use, especially smoking
b. Alcohol use each day
c. Exercise and activity level
d. Dietary intake of Vitamin D
e. Use of calcium supplements
f. Medication history - Answers a,b,c,d,e,f (all of them)
Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for
further teaching by the nurse?
a. "I am going to continue having my DXA scans as my doctor orders."
b. "I will drink only a half glass of wine occasionally to help me sleep."
c. "I plan to increase calcium and vitamin D foods in my diet."
d. "I am going to jog every day for at least 30 minutes." - Answers d. "I am going to jog daily for 30
minutes" (jogging is a high intensity exercise that is not recommended for people at risk for
osteoporosis, something better like swimming or walking should be encouraged)
A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is
holding the splint in place. What is the nurse's best initial action?
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 elastic bandage. - Answers b. neurovascular check (for compartment
syndrome)
A client has a synthetic cast placed for a right wrist fracture in the emergency room. What priority health
teaching is important for the nurse to provide for this client before returning home? (Select all that
apply.)
a. "Keep your right arm below the level of your heart as often as possible."
b. "Use an ice pack for the first 24 hours to decrease tissue swelling."
A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is
holding the splint in place. What is the nurse's best initial action?
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 elastic bandage. - Answers b. perform a neurovascular assessment
The nurse is caring for an older adult client with heat exhaustion. What assessment finding indicates to
the nurse that the client may need hospitalization?
a. Alert and oriented
b. Reports nausea and weakness
c. Continues to sweat while being cooled
d. Mucous membranes are dry and sticky. - Answers d.
The community nurse is educating a client about frostbite prevention. Which factors will the nurse teach
that are risk factors for developing frostbite? (Select all that apply.)
a. Dehydration
b. Smoking history
c. Previous frostbite
d. Excessive fatigue
e. Smoking
f. Wearing wool socks
g. History of diabetes - Answers a,b,c,d,e,g (wearing wool socks is a good prevention against frostbite,
the rest are risk factors)
After 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 multiple 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 - Answers d. 61 y/o w/ SOB = Red
Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation
adequacy?
a. Increased skin turgor
b. Decreased pulse pressure
c. Decreased core body temperature
d. Decreased urine specific gravity - Answers d. decreased urine specific gravity (indicates more water in
the urine and skin turgor is not as accurate)
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe
burn injury? (Select all that apply.)
a. Place client in isolation.
b. Encourage multiple 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 after cleaning and dressing of one wound area, before cleaning and dressing another. -
Answers a,c,d (e decreases the risk of auto-contamination not cross-contamination)
The nurse is encouraging range-of-motion exercises for the client, who states, "this hurts terribly; I don't
want to do this." Identify the appropriate nursing response(s). (Select all that apply.)
a. "You have to do the exercises to get well."
b. "Range-of-motion 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 medication."
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." - Answers 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. Fatigue
c. Glossitis
d. Jaundice
e. pain
f. Microcytic red blood cells
g. Paresthesias of the hands and feet
h. Tachycardia - Answers a,b,e,h (not microcytic 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 additional assessment data are most important to obtain?
a. Blood glucose
b. Any recent infections
c. Any fatigue related to exercise
d. Pulse oximetry and respiratory assessment - Answers 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 medication and needs provider orders
, d. No, she will be fine. - Answers a. Yes (O2 is a staple in managing SCD)
What additional assessment data will the nurse collect from an older Euro-American (white) woman to
determine the client's risk for osteoporosis? (Select all that apply.)
a. Tobacco use, especially smoking
b. Alcohol use each day
c. Exercise and activity level
d. Dietary intake of Vitamin D
e. Use of calcium supplements
f. Medication history - Answers a,b,c,d,e,f (all of them)
Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for
further teaching by the nurse?
a. "I am going to continue having my DXA scans as my doctor orders."
b. "I will drink only a half glass of wine occasionally to help me sleep."
c. "I plan to increase calcium and vitamin D foods in my diet."
d. "I am going to jog every day for at least 30 minutes." - Answers d. "I am going to jog daily for 30
minutes" (jogging is a high intensity exercise that is not recommended for people at risk for
osteoporosis, something better like swimming or walking should be encouraged)
A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is
holding the splint in place. What is the nurse's best initial action?
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 elastic bandage. - Answers b. neurovascular check (for compartment
syndrome)
A client has a synthetic cast placed for a right wrist fracture in the emergency room. What priority health
teaching is important for the nurse to provide for this client before returning home? (Select all that
apply.)
a. "Keep your right arm below the level of your heart as often as possible."
b. "Use an ice pack for the first 24 hours to decrease tissue swelling."
