ATI Med-Surg Test Banks

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.

2. 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.

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

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.

4. 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 antiemetics 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.

3) Thick, red-colored urine

Answer Rationale:

The nurse should recognize viscous drainage that is red in color may

indicatehemorrhage 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 inthe 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 tothe provider.

5. A nurse is caring for a client who has a temperature of 39.7° C (103.5°

F) and hasa 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 ofinfection is hyperthermia