ATI MED-SURG TEST BANKS GRADED A LATREST VERSION 2023 NGN QUESTIONS INCLUDED WITH RATIONALE/A GRADE

4.4

hing? 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 temperatu...

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hing? 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. ATI MED-SURG TEST BANKS GRADED A LATREST VERSION 2023 NGN QUESTIONS INCLUDED WITH RATIONALE/A GRADE INCORRECT 4) Hyperventilate the client with 100% oxygen before suctioning the airway. ATI MED-SURG TEST BANKS GRADED A LATREST VERSION 2023 NGN QUESTIONS INCLUDED WITH RATIONALE/A GRADE 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 slipp

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