ATI MED SURG TESTBANK
1. A nurse is reinforcing teaching with a client who has HIV and is
being dischargedto home. Which of the following instructions
should the nurse include in the teaching?
1) Take temperature once a day.
Answer : Rationale:
The nurse should reinforce to the client to take his temperature
once a daily to identifyif a temperature is present due to the client’s
altered immune system.
INCORRECT
2) Wash the armpits and genitals with a gentle cleanser
daily.
Answer : Rationale:
The nurse should instruct the client to use an antimicrobial cleanser
to wash his armpitsand genitals twice daily.
INCORRECT
3) Change the litter boxes while wearing gloves.
Answer : Rationale:
The client should avoid changing litter boxes. Litter boxes carry
toxoplasmosis whichcan be life threatening to a client who has
HIV.
INCORRECT
4) Wash dishes in warm water.
Answer : Rationale:
The nurse should instruct the client to wash dishes in hot soapy
,water to destroy thebacteria.
1. A nurse is caring for a client who is postoperative following a
tracheostomy, andhas copious and tenacious secretions.
Which of the following is an acceptable method for the nurse
to use to thin this client's secretions?
1) Provide humidified oxygen.
Answer : Rationale:
Increasing fluid intake as tolerated and providing adequate
humidification can help thinsecretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning.
Answer : Rationale:
Performing chest physiotherapy mobilizes secretions but does not
thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile
saline when suctioning theairway.
Answer : Rationale:
Prelubricating the suction catheter tip with sterile saline helps to
ease the insertion ofthe 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 noeffect on the tenacity of the client's secretions.
2. Following admission, a client with a vascular occlusion of
the right lower extremity calls the nurse and reports
difficulty sleeping because of cold feet.Which of the
following nursing actions should the nurse take to promote
the client's comfort?
INCORRECT
1) Rub the client's feet briskly for several minutes.
Answer : Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial
or venous circulationof the lower extremities is a contraindication
for leg massage.
2) Obtain a pair of slipper socks for the client.
Answer : Rationale:
Slipper socks with nonskid soles will help provide warmth and
increase the client's levelof comfort.
INCORRECT
3) Increase the client's oral fluid intake.
Answer : Rationale:
Increasing the client's fluid intake will not increase circulation to an
area an occlusionimpairs.
INCORRECT
4) Place a moist heating pad under the client's feet.
, Answer : Rationale:
Impaired arterial or venous circulation to a lower extremity is a
contraindication forapplying a heating pad.
3. A nurse is caring for a client is who is 4 hr postoperative
following a transurethralresection of the prostate (TURP).
Which of the following is the priority finding for the nurse
report to the provider?
INCORRECT
1) Emesis of
100 mL
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 providesupportive measures; however,
it is not the priority finding.
INCORRECT
2) Oral temperature 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.
1. A nurse is reinforcing teaching with a client who has HIV and is
being dischargedto home. Which of the following instructions
should the nurse include in the teaching?
1) Take temperature once a day.
Answer : Rationale:
The nurse should reinforce to the client to take his temperature
once a daily to identifyif a temperature is present due to the client’s
altered immune system.
INCORRECT
2) Wash the armpits and genitals with a gentle cleanser
daily.
Answer : Rationale:
The nurse should instruct the client to use an antimicrobial cleanser
to wash his armpitsand genitals twice daily.
INCORRECT
3) Change the litter boxes while wearing gloves.
Answer : Rationale:
The client should avoid changing litter boxes. Litter boxes carry
toxoplasmosis whichcan be life threatening to a client who has
HIV.
INCORRECT
4) Wash dishes in warm water.
Answer : Rationale:
The nurse should instruct the client to wash dishes in hot soapy
,water to destroy thebacteria.
1. A nurse is caring for a client who is postoperative following a
tracheostomy, andhas copious and tenacious secretions.
Which of the following is an acceptable method for the nurse
to use to thin this client's secretions?
1) Provide humidified oxygen.
Answer : Rationale:
Increasing fluid intake as tolerated and providing adequate
humidification can help thinsecretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning.
Answer : Rationale:
Performing chest physiotherapy mobilizes secretions but does not
thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile
saline when suctioning theairway.
Answer : Rationale:
Prelubricating the suction catheter tip with sterile saline helps to
ease the insertion ofthe 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 noeffect on the tenacity of the client's secretions.
2. Following admission, a client with a vascular occlusion of
the right lower extremity calls the nurse and reports
difficulty sleeping because of cold feet.Which of the
following nursing actions should the nurse take to promote
the client's comfort?
INCORRECT
1) Rub the client's feet briskly for several minutes.
Answer : Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial
or venous circulationof the lower extremities is a contraindication
for leg massage.
2) Obtain a pair of slipper socks for the client.
Answer : Rationale:
Slipper socks with nonskid soles will help provide warmth and
increase the client's levelof comfort.
INCORRECT
3) Increase the client's oral fluid intake.
Answer : Rationale:
Increasing the client's fluid intake will not increase circulation to an
area an occlusionimpairs.
INCORRECT
4) Place a moist heating pad under the client's feet.
, Answer : Rationale:
Impaired arterial or venous circulation to a lower extremity is a
contraindication forapplying a heating pad.
3. A nurse is caring for a client is who is 4 hr postoperative
following a transurethralresection of the prostate (TURP).
Which of the following is the priority finding for the nurse
report to the provider?
INCORRECT
1) Emesis of
100 mL
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 providesupportive measures; however,
it is not the priority finding.
INCORRECT
2) Oral temperature 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.
