ATI MED-SURG TEST BANK LATEST 2022-2023 QUESTIONS
AND CORRECT ANSWERS PLUS RATIONALES (VERIFIED
ANSWERS) |A+ GRADE
1. A nurse is reinforcing teaching with a client w h o has HIV and is
being discharged to h o m e . W hich of the following instructions
should the nurse include in the teaching?
1) Take temperat ure on ce a day.
Answer Rationale:
The nurse should reinforce to the client to take his temperature once
a daily to identify if a temperature is present due to the client’s
altered immune system.
INCORRECT
2) W a s h t he a rm pits a n d gen it al s w ith a gen t l e c l e a n s e r daily.
Answer Rationale:
T h e nurse should instruct the client to use a n antimicrobial cleanser to
wa sh his armpits and genitals twice daily.
INCORRECT
3) C h a n g e t he litter b o x e s w hile w e a r i n g gl o v es .
Answer Rationale:
T h e client should avoid changing litter boxes. Litter boxes carry
toxoplasmosis which can b e life threatening to a client w h o has HIV.
INCORRECT
4) Wa s h dishes in warm water.
Answer Rationale:
The nurse should instruct the client to wash dishes in hot soapy water
to destroy the bacteria.
2. A nurse is caring for a client w h o is postoperative following a
tracheostomy, and has copious and tenacious secretions. W hich
of the following is a n acceptable me th od for the nurse to use to
thin this client's secretions?
1) Provide humidified o xy gen.
Answer Rationale:
Increasing fluid intake as tolerated and providing adequate
humidification can help thin secretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning.
, Answer Rationale:
Performing chest physiotherapy mobilizes secretions bu t does not thin
them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline w h e n
suctioning the airway.
Answer Rationale:
Prelubricating the suction catheter tip with sterile saline helps to
ease the insertion of the catheter, producing less trauma. However, it
has no effect on the tenacity of the client's secretions.
INCORRECT
4) Hyperventilate the client with 100% oxygen before suctioning
the airway.
, Answer Rationale:
Hyperventilating the client prior to suctioning prevents hypoxia.
However, it has no effect on the tenacity of the client's secretions.
3. Following admission, a client with a vascular occlusion of the
right lower extremity calls the nurse and reports difficulty
sleeping because of cold feet. W hich of the following nursing
actions should the nurse take to promote the client's
comfort?
INCORRECT
1) R u b t he client's f eet briskly f o r s ev e r a l m in u t es .
Answer Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or
venous circulation of the lower extremities is a contraindication for
leg massage.
2) O b t a i n a p a ir o f slipp er s o c k s f o r t he cl ient.
Answer Rationale:
Slipper socks with nonskid soles will help provide w a r m t h and increase
the client's level of comfort.
INCORRECT
3) I n c rea s e t h e client's o ra l fluid in t a ke.
Answer Rationale:
Increasing the client's fluid intake will not increase circulation to an
area an occlusion impairs.
INCORRECT
4) Pl a ce a m oist h e a t in g p a d u n d e r t h e client's f eet .
Answer Rationale:
Impaired arterial or venous circulation to a lower extremity is a
contraindication for applying a heating pad.
4. A nurse is caring for a client is who is 4 hr postoperative
following a transurethral resection of the prostate (TURP). Which
of the following is the priority finding for the nurse report to the
provider?
INCORRECT
1) Emesis o f 100 m L
Answer Rationale:
The nurse should recognize postoperative nausea is a complication
related to the administration of anesthesia and should treat the nausea
with anti-emetics and provide supportive measures; however, it is not
the priority finding.
INCORRECT
2) Oral temperatu re of 37.5° C (99.5° F)
Answer Rationale:
The nurse should monitor a client who develops a fever and
encourage deep breathing, coughing, and fluid intake (if permitted);
however, it is not the priority finding to report. The increase in
temperature is likely due to decreased respiratory effort related to the
use of anesthesia and should clear with pulmonary hygiene.
, 3) Thick, red-colored urine
Answer Rationale:
T h e nurse should recognize viscous drainage that is red in color m a y
indicate hemorrhage and should b e reported to the provider
immediately.
INCORRECT
4) Pa in l ev el o f 4 o n a 0 to 1 0 rat in g scale
Answer Rationale:
T h e nurse should assess for and treat postoperative pain which is a n
expected finding in the postoperative client; ho wev e r it is not the
priority finding to report. Specific pain, such a s bladder spasms, m a y
indicate complications howev er and should b e reported to the provider.
5. A nurse is caring for a client w h o has a temperature of 39.7° C
(103.5° F ) and has a prescription for a hypothermia blanket. The
nurse should m onitor the client for which of the following
adverse effects of the hypothermia blanket?
1) Shiv ering
Answer Rationale:
The hypothermia blanket can cause shivering if the client is cooled
too quickly. Shivering can cause the client’s temperature to increase.
INCORRECT
2) Infection
Answer Rationale:
Infection is not a complication of the hypothermia blanket therapy. A
manifestation of infection is hyperthermia.
INCORRECT
3) B u r n s
Answer Rationale:
Burns are associated with the imp ro per use of heating pads, not
hypothermia blankets.
INCORRECT
4) Hypervolemia
Answer Rationale:
Hypervolemia is not a complication of the hypothermia blanket
therapy. Dehydration is a risk associated with hyperthermia due to
fluid loss.
6. A nurse is reinforcing teaching about exercise with a client
w h o has type 1 diabetes mellitus. Whi c h of the following
statements b y the client indicates an understanding of the
teaching?
INCORRECT
1) "I will carry a com pl ex carbohydrate snack with m e w h e n I
exercise."
Answer Rationale:
T h e nurse should reinforce that the client should carry a simple
carbohydrate such a s hard candy or glucose tablets for use during
exercise if the client b e c o m e s hypoglycemic.
INCORRECT
AND CORRECT ANSWERS PLUS RATIONALES (VERIFIED
ANSWERS) |A+ GRADE
1. A nurse is reinforcing teaching with a client w h o has HIV and is
being discharged to h o m e . W hich of the following instructions
should the nurse include in the teaching?
1) Take temperat ure on ce a day.
Answer Rationale:
The nurse should reinforce to the client to take his temperature once
a daily to identify if a temperature is present due to the client’s
altered immune system.
INCORRECT
2) W a s h t he a rm pits a n d gen it al s w ith a gen t l e c l e a n s e r daily.
Answer Rationale:
T h e nurse should instruct the client to use a n antimicrobial cleanser to
wa sh his armpits and genitals twice daily.
INCORRECT
3) C h a n g e t he litter b o x e s w hile w e a r i n g gl o v es .
Answer Rationale:
T h e client should avoid changing litter boxes. Litter boxes carry
toxoplasmosis which can b e life threatening to a client w h o has HIV.
INCORRECT
4) Wa s h dishes in warm water.
Answer Rationale:
The nurse should instruct the client to wash dishes in hot soapy water
to destroy the bacteria.
2. A nurse is caring for a client w h o is postoperative following a
tracheostomy, and has copious and tenacious secretions. W hich
of the following is a n acceptable me th od for the nurse to use to
thin this client's secretions?
1) Provide humidified o xy gen.
Answer Rationale:
Increasing fluid intake as tolerated and providing adequate
humidification can help thin secretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning.
, Answer Rationale:
Performing chest physiotherapy mobilizes secretions bu t does not thin
them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline w h e n
suctioning the airway.
Answer Rationale:
Prelubricating the suction catheter tip with sterile saline helps to
ease the insertion of the catheter, producing less trauma. However, it
has no effect on the tenacity of the client's secretions.
INCORRECT
4) Hyperventilate the client with 100% oxygen before suctioning
the airway.
, Answer Rationale:
Hyperventilating the client prior to suctioning prevents hypoxia.
However, it has no effect on the tenacity of the client's secretions.
3. Following admission, a client with a vascular occlusion of the
right lower extremity calls the nurse and reports difficulty
sleeping because of cold feet. W hich of the following nursing
actions should the nurse take to promote the client's
comfort?
INCORRECT
1) R u b t he client's f eet briskly f o r s ev e r a l m in u t es .
Answer Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or
venous circulation of the lower extremities is a contraindication for
leg massage.
2) O b t a i n a p a ir o f slipp er s o c k s f o r t he cl ient.
Answer Rationale:
Slipper socks with nonskid soles will help provide w a r m t h and increase
the client's level of comfort.
INCORRECT
3) I n c rea s e t h e client's o ra l fluid in t a ke.
Answer Rationale:
Increasing the client's fluid intake will not increase circulation to an
area an occlusion impairs.
INCORRECT
4) Pl a ce a m oist h e a t in g p a d u n d e r t h e client's f eet .
Answer Rationale:
Impaired arterial or venous circulation to a lower extremity is a
contraindication for applying a heating pad.
4. A nurse is caring for a client is who is 4 hr postoperative
following a transurethral resection of the prostate (TURP). Which
of the following is the priority finding for the nurse report to the
provider?
INCORRECT
1) Emesis o f 100 m L
Answer Rationale:
The nurse should recognize postoperative nausea is a complication
related to the administration of anesthesia and should treat the nausea
with anti-emetics and provide supportive measures; however, it is not
the priority finding.
INCORRECT
2) Oral temperatu re of 37.5° C (99.5° F)
Answer Rationale:
The nurse should monitor a client who develops a fever and
encourage deep breathing, coughing, and fluid intake (if permitted);
however, it is not the priority finding to report. The increase in
temperature is likely due to decreased respiratory effort related to the
use of anesthesia and should clear with pulmonary hygiene.
, 3) Thick, red-colored urine
Answer Rationale:
T h e nurse should recognize viscous drainage that is red in color m a y
indicate hemorrhage and should b e reported to the provider
immediately.
INCORRECT
4) Pa in l ev el o f 4 o n a 0 to 1 0 rat in g scale
Answer Rationale:
T h e nurse should assess for and treat postoperative pain which is a n
expected finding in the postoperative client; ho wev e r it is not the
priority finding to report. Specific pain, such a s bladder spasms, m a y
indicate complications howev er and should b e reported to the provider.
5. A nurse is caring for a client w h o has a temperature of 39.7° C
(103.5° F ) and has a prescription for a hypothermia blanket. The
nurse should m onitor the client for which of the following
adverse effects of the hypothermia blanket?
1) Shiv ering
Answer Rationale:
The hypothermia blanket can cause shivering if the client is cooled
too quickly. Shivering can cause the client’s temperature to increase.
INCORRECT
2) Infection
Answer Rationale:
Infection is not a complication of the hypothermia blanket therapy. A
manifestation of infection is hyperthermia.
INCORRECT
3) B u r n s
Answer Rationale:
Burns are associated with the imp ro per use of heating pads, not
hypothermia blankets.
INCORRECT
4) Hypervolemia
Answer Rationale:
Hypervolemia is not a complication of the hypothermia blanket
therapy. Dehydration is a risk associated with hyperthermia due to
fluid loss.
6. A nurse is reinforcing teaching about exercise with a client
w h o has type 1 diabetes mellitus. Whi c h of the following
statements b y the client indicates an understanding of the
teaching?
INCORRECT
1) "I will carry a com pl ex carbohydrate snack with m e w h e n I
exercise."
Answer Rationale:
T h e nurse should reinforce that the client should carry a simple
carbohydrate such a s hard candy or glucose tablets for use during
exercise if the client b e c o m e s hypoglycemic.
INCORRECT
