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.
2) Wash the armpits and genitals with a gentle cleanser daily.
3) Change the litter boxes while wearing gloves.
4) Wash dishes in warm water.
1. 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.
2) Perform chest physiotherapy prior to suctioning.
3) Prelubricate the suction catheter tip with sterile saline when suctioning
the airway.
4) Hyperventilate the client with 100% oxygen before suctioning the
airway..
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?
1) Rub the client's feet briskly for several minutes.
2) Obtain a pair of slipper socks for the client.
3) Increase the client's oral fluid intake.
4) Place a moist heating pad under the client's feet.
3. 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?
1) Emesis of 100 mL
2) Oral temperature of 37.5° C (99.5° F)
3) Thick, red-colored urine
4) Pain level of 4 on a 0 to 10 rating scale
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