ATI- Module 3 Fundamentals: Safety and Infection

ATI- Module 3 Fundamentals: Safety and Infection A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? -Change tracheostomy ties when soiled. ...

ATI- Module 3 Fundamentals: Safety and Infection A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? -Change tracheostomy ties when soiled. 2) A client has fallen in the bathroom. Which of the following is the priority nursing action? -Assess the client’s level of consciousness 3) A nurse is providing discharge education for a female client diagnosed with Chlamydia. Which statement made by the client would indicate the need for further instruction? -“I will return to the clinic in one month for re-screening. 4) A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C (105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an Unlicensed Assistive Personnel (UAP)? -Report shivering by the client 5) A nurse is triaging clients following a mass casualty event. The nurse should place a client who has sustained fatal injuries in which of the following triage categories? - Expectant Category (Class IV) 6) A nurse is positioning a client for a urinary catheterization. Which of the following nursing actions would be best in preventing musculoskeletal injuries during the procedure? -Raising the bed to a comfortable height. 7) A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client’s risk for falls? -Hourly rounding by the nurse. 8) A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another building. Which of the following clients would have the highest priority for the charge nurse to evacuate? - A client receiving IV antibiotics every six hours for a leg ulcer. 9) A nurse is providing the family of a client with acquired immunodeficiency syndrome (AIDS) education in preparation for discharge. A family member asks about appropriate clean up of blood or body fluids. Which of the following is the correct response by the nurse? - Disinfect the area with a 10% bleach solution after initial cleaning. 10) A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2 hours. Which intervention is the priority? -Fill out an incident report 11) A graduate nurse is caring for a client who is on neutropenic precautions. Which of the following actions by the nurse would require further teaching by the charge nurse? - Discarding an empty blood bag and blood tubing in the client’s beside trash can. 12) A newly-licensed nurse is preparing the surgical suite for a client who has a latex allergy. Which action demonstrates a need for further education? - Scheduling the case late in the day. 13) A nurse is orienting a newly licensed nurse to the operating room. Which of the following actions by the new nurse indicates a need for further education about surgical aseptic hand hygiene? - Rinsing hands and arms while keeping them lower than elbows 14) A client has just returned to the surgical unit after an open cholestectomy. A nurse notes the abdominal dressing is saturated with sanguineous drainage. Which of the following is the most appropriate intervention? - Reinforce the dressing with additional gauze. 15) The parents of an adolescent client ask the nurse why the meningiococcal conjugate vaccine is recommended before attending college. Which of the following statements best explains the reason why college-aged students should receive this vaccine? - Living in a dormitory increases the risk of exposure to the disease 16) A nurse is instructing a client with a right fractured tibia on the correct technique for using a three-point gait with crutches. Which of the following should be included in teaching? - Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated 17) A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? - Once my baby begins to roll over it is okay to use a small pillow in the crib. 18) A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? - We will need to remove the baby’s ankle identification band during diaper changes. 19) A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and blood pressure of 132/88. Which of the following is the priority nursing intervention? - Reassess pulse oximetry 20) A nurse is caring for a client diagnosed