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.