the nurse is caring for an older adult client with
which assessment finding does the nurse interpret
which signs and symptoms does the nurse expect to
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Voorbeeld van de inhoud
CHII EXAM 4 (MSK, HEMATOLOGY, ER &
REPRODUCTIVE) QUESTIONS WITH ALL
SOLVED CORRECTLY TO PASS!!
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. Answer - 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. Answer - 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 Answer - 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 Answer
- 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 Answer - 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. Answer - 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." Answer - 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 Answer - 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 Answer - 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. Answer - 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
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