ATI Med-Surg Test Banks
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for
which of the following adverse effects of the hypothermia blanket?
hivering
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) Burns
Answer Rationale:
Burns are associated with the improper 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.
A nurse is reinforcing teaching with a client who has HIV and is being discharged
to home. Which of the following instructions should the nurse include in the
teaching?
1) T
ake temperature once 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) 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 armpits and 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
which can 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
the bacteria.
A nurse is caring for a client who is postoperative following a tracheostomy, and
has copious and tenacious secretions. Which of the following is an acceptable
method for the nurse to use to thin this client's secretions?
Provide humidified oxygen.
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 but does not thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline when 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. F
ollowing 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
circulation of 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
level of 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
occlusion impairs.
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 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 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
provide supportive 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.
A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for
which of the following adverse effects of the hypothermia blanket?
hivering
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) Burns
Answer Rationale:
Burns are associated with the improper 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.
A nurse is reinforcing teaching with a client who has HIV and is being discharged
to home. Which of the following instructions should the nurse include in the
teaching?
1) T
ake temperature once 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) 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 armpits and 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
which can 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
the bacteria.
A nurse is caring for a client who is postoperative following a tracheostomy, and
has copious and tenacious secretions. Which of the following is an acceptable
method for the nurse to use to thin this client's secretions?
Provide humidified oxygen.
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 but does not thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline when 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. F
ollowing 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
circulation of 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
level of 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
occlusion impairs.
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 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 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
provide supportive 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.
