VATI Safety and infection control exam 2023 with 100% correct answers

A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? Change tracheostomy ties when soiled. A client has fallen in the bathroom. Which of the following is the priority nursing action? Assess the client's level of consciousness CORRECT. Safety first. Before proceeding with the assessment or taking vital signs assess the level of consciousness. Complaints of pain, any joint or bone deformity may provide evidence of fractures or dislocations. Inspection of the skin will determine lacerations, contusions, or hematomas that may need to be treated. After a report to the provider, additional x-rays or exams may be ordered. 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? Will return to the clinic in one month for re-screening 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 CORRECT. The unlicensed assistive personnel should be taught to observe for and report shivering during any form of external cooling. Shivering may indicate that the client is being cooled too quickly. 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) CORRECT. Class IV (Expectant Category) is reserved for clients who are not expected to live and will be allowed to die naturally. Comfort measures may be provided, but restorative care will not. These clients are the lowest priority when a mass casualty has occurred. 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. CORRECT. Working with the bed at a comfortable height is more ergonomically appropriate to prevent back strain and possible injury, to prevent bending and/or twisting from the waist. 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. CORRECT. In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction. 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. CORRECT. The client with a leg ulcer can walk unassisted without an IV pole. In a hospital evacuation, unlike triage and evacuation outside of the hospital, the most stable, ambulatory clients will be evacuated first, followed by those who need assistance with mobility (wheelchairs) or equipment (tubes, catheters), and finally those who need to be moved by stretcher or in their hospital beds. The prevailing concept is to move as many clients as quickly and safely as possible from the area.