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
... [Show More] 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 [Show Less]