ATI Med-Surg Test Banks

1. 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) Take 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.

2. 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?

1) 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. 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 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.

3) Thick, red-colored urine

Answer Rationale:

The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and should be

reported to the provider immediately.

INCORRECT

4) Pain level of 4 on a 0 to 10 rating scale

Answer Rationale:

The nurse should assess for and treat postoperative pain which is an expected finding in the postoperative

client; however it is not the priority finding to report. Specific pain, such as bladder spasms, may indicate

complications however and should be reported to the provider.

5. 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?

1) Shivering

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.