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ATI MED-SURG TEST BANK 2019 LATEST UPDATES QUESTION AND ANSWERS WITH EXPLANATION GRADED AS PER MARKING SCHEME. (MS ATI Immune and Infectious). ALL LATEST VERSION.£21.49
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ATI MED-SURG TEST BANK 2019 LATEST UPDATES QUESTION AND ANSWERS WITH EXPLANATION GRADED AS PER MARKING SCHEME. (MS ATI Immune and Infectious). ALL LATEST VERSION.
ATI MED-SURG TEST BANK 2019 LATEST UPDATES QUESTION AND ANSWERS WITH EXPLANATION GRADED AS PER MARKING SCHEME. (MS ATI Immune and Infectious). ALL LATEST VERSION.
ATI MED-SURG TEST BANK 2019 LATEST
UPDATES QUESTION AND ANSWERS WITH
EXPLANATION GRADED AS PER MARKING
SCHEME. (MS ATI Immune and Infectious).
ALL LATEST VERSION.
(55)
1. A nurse is assisting with the care of a client who has human immunodeficiency virus (HIV).
Which of the following types of isolation should the nurse implement to prevent the transmission
of HIV?
A. Protective isolation.
B. Droplet precautions.
C. Standard precautions.
D. Airborne precautions.
Answer: Standard precautions.
Standard precautions should be implemented with every client to prevent the spread of infection
transmitted by direct or indirect contact with infectious blood or body fluids. Because HIV is
spread through blood and body fluids, standard precautions are appropriate.
Protective isolation keeps a client who is immunocompromised from acquiring communicable
infections prevalent in the hospital setting. This measure does not prevent the transmission of
HIV.
Droplet precautions prevent the transmission of infectious diseases over short distances via air
droplets. HIV is not spread by air droplets; therefore, droplet precautions are not necessary.
Airborne precautions are measures taken to prevent the spread of diseases transmitted by the air.
HIV is not spread by the air; therefore, airborne precautions are not necessary.
2. A nurse is collecting preoperative data from a client who is about to undergo a
cholecystectomy. The nurse should identify a risk for latex allergy when the client reports an
allergy to which of the following foods? A. Cabbage.
B. Oatmeal.
C. Milk.
D. Bananas.
Answer: Bananas.
An allergy to bananas is a risk factor that indicates the client could also be allergic to latex.
Other cross-reactive foods include avocados, kiwi, chestnuts, mangoes, pineapple, and passion
,fruit. The health care team should wear nonlatex gloves and use only latex-free supplies when
caring for this client.
There is no known association between a latex allergy and a cabbage allergy.
There is no known association between a latex allergy and an oatmeal allergy. There
is no known association between a latex allergy and a milk allergy.
3. A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile
infection. Which of the following interventions is the nurse’s priority? A. Performing hand
hygiene before and after contact with the client.
B. Reducing the client’s anxiety due to isolation procedures.
C. Assisting the client with making nutritional choices. D. Monitoring the
client’s intake and output.
Answer: A. Performing hand hygiene before and after contact with the client.
The nurse should apply the safety and risk-reduction priority-setting framework, which assigns
priority to the factor or situation posing the greatest safety risk to the client. When there are
several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse
should use Maslow’s hierarchy of needs, the ABC priority-setting framework, and/or nursing
knowledge to identify which risk poses the greatest threat to the client. C. difficile is a
sporeforming, gram-positive anaerobic bacillus that produces 2 virulent exotoxins to attack the
lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques)
of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The
spores spread easily by contact with body fluids and inanimate objects. The greatest risk to this
client, the nurse, and others is injury from infection transmission; therefore, the priority
intervention is hand hygiene.
The client is at risk of anxiety because of illness and isolation; however, another intervention is
the priority.
The client is at risk of malnutrition because of diarrhea; however, another intervention is the
priority.
The client is at risk of dehydration because of diarrhea; however, another intervention is the
priority.
4. A nurse is reinforcing teaching with a client who has AIDS about preventing infection while at
home. Which of the following instructions should the nurse include in the teaching? A. Wash
genitalia using an antimicrobial soap.
B. Rinse dishes with cold water.
C. Clean toothbrush once per month.
D. Incorporate raw fruits and vegetables into the diet.
Answer: Wash genitalia using an antimicrobial soap.
, The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the
spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap
is recommended.
Dishes should be washed using hot, sudsy water.
The client’s toothbrush should be cleaned once per week by running it through the dishwasher or
rinsing it with bleach.
Raw fruits and vegetables should be avoided due to the bacteria they carry.
5. A nurse is collecting data from a client who is experiencing an acute exacerbation of
rheumatoid arthritis. The nurse should anticipate that the client's affected joints will require
which of the following treatments?
A. Assistive device to use when the client is ambulating.
B. Heat paraffin therapy applied to the client’s hands.
C. Gentle massage of the client’s joints.
D. Active range-of-motion exercises on the client’s affected joints.
Answer: Heat paraffin therapy applied to the client’s hands.
The nurse should anticipate the use of heat paraffin to be prescribed as a non-pharmacological
intervention. The elevated ESR indicates an acute inflammatory process due to the client’s
rheumatoid arthritis. The use of warm paraffin relieves the stiffness of the client’s joints, as well
as providing comfort.
Clients who have rheumatoid arthritis do not need assistive devices. An assistive device is only
needed when a severe loss of range-of-motion occurs.
C. Massage can aggravate inflammation. Most clients have a tendency to rub inflamed, aching
joints but should be taught instead to massage over surrounding muscles.
During exacerbations of rheumatoid arthritis, active range-of-joint motion exercises should not
be performed; only passive or isometric exercises are indicated.
6. A nurse is preparing to administer a Mantoux skin test to a client. What is the purpose of a
Mantoux skin test using purified protein derivative (PPD)?
A. To identify whether a client lacks immunity to tuberculosis.
B. To find out if a client has active tuberculosis.
C. To decrease the hypersensitivity of the client's reaction to PPD.
D. To identify whether a client has been infected with Mycobacterium tuberculosis.
Answer: To identify whether a client has been infected with Mycobacterium tuberculosis.
The nurse should inform the client that the Mantoux skin test is used to identify individuals who
have been infected with Mycobacterium tuberculosis.
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