ATI - MEDSURG IMMUNE AND
INFECTIONS LATEST EXAM
WITH RATIONALES |ACTUAL
EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS
|ALREADY GRADED A+
A nurse is assisting with the care of a client who is 2 days postoperative. Which of
the following findings should alert the nurse that the client is developing an
infection?
A. Temperature 100 F
B. Erythema at the incision site
C. WBC count 9,000/mm3
D. Pain reported as a 6 on a 0 to 10 pain rating scale - ANSWER✅✅ -B.
Erythema at the incision site
Rationale: Redness, or erythema, at the incision site is an initial manifestation of a
wound infection and requires intervention by the nurse. A temperature of 37.8° C
(100° F) is within the expected reference range and does not indicate the client is
developing an infection. This WBC count is within the expected reference range
and does not indicate the client is developing an infection. The expected reference
range for WBC count is between 5,000 to 10,000/mm3. A pain level of 6 on a 0 to
10 scale for a client who is 2 days postoperative without any other significant
findings does not indicate the client is developing an infection. The client should
be medicated for pain promptly.
,A nurse is reinforcing teaching with a client who has tested positive for an allergy
to dust about how to reduce her exposure to the allergen. The nurse should
determine that the client understands how to reduce her exposure to this allergen
when she states which of the following?
A. "I will begin vacuuming once a week"
B. "Carpeting the entire house will be very expensive, but it will be worth it"
C. "I will install an electrostatic filter in my furnace"
D. "Installing curtains on the windows will help control the dust in the house" -
ANSWER✅✅ -C. "I will install an electrostatic filter in my furnace"
Rationale: The nurse should instruct the client to install an electrostatic filter in her
furnace to control the amount of dust in the home environment. The nurse should
instruct the client to vacuum daily to decrease the amount of dust in the client's
environment. The nurse should instruct the client that carpeting should be removed
from as many rooms as possible, especially from the bedroom or any other
common areas where the client spends time. Carpet accumulates large amounts of
dust in the client's environment. The nurse should instruct the client to remove
curtains within the house and replace them with pull shades. Pull shades
accumulate less dust than curtains and can be easier to clean.
A nurse is reinforcing discharge teaching with the partner of a client who has
acquired immunodeficiency syndrome (AIDS). Which of the following statements
by the client's partner indicates the need for further teaching?
A. "I will dispose spoiled tissues in separate plastic bags"
B. "I'll clean up blood spills immediately with hot water"
C. I know that hand washing is an important preventive measure"
, D. "I will wash soiled clothes in hot water" - ANSWER✅✅ -B. "I'll clean up
blood spills immediately with hot water"
Rationale: The client's partner should clean blood or potentially contaminated body
substances with a bleach solution and wear gloves when coming into contact with
blood products. The client's partner should use a separate plastic bag to dispose
soiled tissues. Any items that cannot be disposed of in the toilet should be kept in a
closed plastic bag until trash disposal. The client's partner should implement
measures such as hand washing to prevent the spread of infection. The client's
partner should wash soiled clothes in hot water along with 1 cup of bleach to clean
clothing.
A nurse is collecting data from a client who has an exacerbation of herpes zoster.
Which of the following manifestations of the client's skin should the nurse expect
to see?
A. Confluent, honey-colored, crusted lesions
B. Large tender nodule located on a hair follicle
C. Unilateral, localized, nodular skin lesions
D. A fluid-filled vesicular rash in the genital region - ANSWER✅✅ -C.
Unilateral, localized, nodular skin lesions
Rationale: Herpes zoster, or shingles, results from the reactivation of a dormant
varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion.
The infection typically develops in adults and produces localized vesicular lesions
confined to a dermatome. It produces unilateral, localized, nodular skin lesions.
Confluent (gathered together), honey-colored, crusted lesions are typically
associated with impetigo. This describes a furuncle or bacterial infection on a hair
follicle. This manifestation indicates genital herpes, which is caused by the herpes
simplex virus.
INFECTIONS LATEST EXAM
WITH RATIONALES |ACTUAL
EXAM QUESTIONS AND
CORRECT VERIFIED ANSWERS
|ALREADY GRADED A+
A nurse is assisting with the care of a client who is 2 days postoperative. Which of
the following findings should alert the nurse that the client is developing an
infection?
A. Temperature 100 F
B. Erythema at the incision site
C. WBC count 9,000/mm3
D. Pain reported as a 6 on a 0 to 10 pain rating scale - ANSWER✅✅ -B.
Erythema at the incision site
Rationale: Redness, or erythema, at the incision site is an initial manifestation of a
wound infection and requires intervention by the nurse. A temperature of 37.8° C
(100° F) is within the expected reference range and does not indicate the client is
developing an infection. This WBC count is within the expected reference range
and does not indicate the client is developing an infection. The expected reference
range for WBC count is between 5,000 to 10,000/mm3. A pain level of 6 on a 0 to
10 scale for a client who is 2 days postoperative without any other significant
findings does not indicate the client is developing an infection. The client should
be medicated for pain promptly.
,A nurse is reinforcing teaching with a client who has tested positive for an allergy
to dust about how to reduce her exposure to the allergen. The nurse should
determine that the client understands how to reduce her exposure to this allergen
when she states which of the following?
A. "I will begin vacuuming once a week"
B. "Carpeting the entire house will be very expensive, but it will be worth it"
C. "I will install an electrostatic filter in my furnace"
D. "Installing curtains on the windows will help control the dust in the house" -
ANSWER✅✅ -C. "I will install an electrostatic filter in my furnace"
Rationale: The nurse should instruct the client to install an electrostatic filter in her
furnace to control the amount of dust in the home environment. The nurse should
instruct the client to vacuum daily to decrease the amount of dust in the client's
environment. The nurse should instruct the client that carpeting should be removed
from as many rooms as possible, especially from the bedroom or any other
common areas where the client spends time. Carpet accumulates large amounts of
dust in the client's environment. The nurse should instruct the client to remove
curtains within the house and replace them with pull shades. Pull shades
accumulate less dust than curtains and can be easier to clean.
A nurse is reinforcing discharge teaching with the partner of a client who has
acquired immunodeficiency syndrome (AIDS). Which of the following statements
by the client's partner indicates the need for further teaching?
A. "I will dispose spoiled tissues in separate plastic bags"
B. "I'll clean up blood spills immediately with hot water"
C. I know that hand washing is an important preventive measure"
, D. "I will wash soiled clothes in hot water" - ANSWER✅✅ -B. "I'll clean up
blood spills immediately with hot water"
Rationale: The client's partner should clean blood or potentially contaminated body
substances with a bleach solution and wear gloves when coming into contact with
blood products. The client's partner should use a separate plastic bag to dispose
soiled tissues. Any items that cannot be disposed of in the toilet should be kept in a
closed plastic bag until trash disposal. The client's partner should implement
measures such as hand washing to prevent the spread of infection. The client's
partner should wash soiled clothes in hot water along with 1 cup of bleach to clean
clothing.
A nurse is collecting data from a client who has an exacerbation of herpes zoster.
Which of the following manifestations of the client's skin should the nurse expect
to see?
A. Confluent, honey-colored, crusted lesions
B. Large tender nodule located on a hair follicle
C. Unilateral, localized, nodular skin lesions
D. A fluid-filled vesicular rash in the genital region - ANSWER✅✅ -C.
Unilateral, localized, nodular skin lesions
Rationale: Herpes zoster, or shingles, results from the reactivation of a dormant
varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion.
The infection typically develops in adults and produces localized vesicular lesions
confined to a dermatome. It produces unilateral, localized, nodular skin lesions.
Confluent (gathered together), honey-colored, crusted lesions are typically
associated with impetigo. This describes a furuncle or bacterial infection on a hair
follicle. This manifestation indicates genital herpes, which is caused by the herpes
simplex virus.
