ATI MED-SURG TEST BANK LATEST 2022-2023 QUESTIONS AND CORRECT ANSWERS PLUS RATIONALES (VERIFIED ANSWERS )|AGRADE

ATI MED-SURG TEST BANK LATEST 2022-2023

QUESTIONS AND CORRECT ANSWERS PLUS RATIONALES

(VERIFIED ANSWERS )|AGRADE

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.

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.

6. A nurse is reinforcing teaching about exercise with a client who has type 1

diabetes mellitus. Which of the following statements by the client indicates an

understanding of the teaching?

INCORRECT

1) "I will carry a complex carbohydrate snack with me when I exercise."

Answer Rationale:

The nurse should reinforce that the client should carry a simple carbohydrate such as hard

candy or glucose tablets for use during exercise if the client becomes hypoglycemic.

INCORRECT

2) "I should exercise first thing in the morning before eating breakfast."

Answer Rationale:

The nurse should reinforce that exercise should follow a meal. Exercising first thing in the

morning on an empty stomach places the client at risk for hypoglycemia.

INCORRECT

3) "I should avoid injecting insulin into my thigh if I am going to go running."

Answer Rationale:

The nurse should reinforce that the client should avoid injecting insulin into an area that

will soon be exercised to avoid increasing the absorption rate of the insulin.

4) "I will not exercise if my urine is positive for ketones."

Answer Rationale:

The nurse should reinforce that exercise should be avoided if ketones are present in the

urine as this indicates an elevated blood glucose level or ketoacidosis.

7. A nurse notes a small section of bowel protruding from the abdominal incision

of a client who is postoperative. After calling for assistance, which of the

following actions should the nurse take first?

1) Cover the client's wound with a moist, sterile dressing.

Answer Rationale:

According to evidence-based practice, the nurse's first action should be to cover the wound

with a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the

tissue moist.

INCORRECT

2) Have the client lie supine with knees flexed.

Answer Rationale: