A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first?
A client who is confused and restrained for safety
A client who is 1 day postoperative following thoracic surgery and has a chest tube
A client who is in Buck's traction for a left hip fracture
A client who is receiving IV chemotherapy and is ambulatory
The Correct Answer is A
Choice A reason: This is the correct choice because this client has the highest risk of injury or death in the event of a fire. The client is confused and may not understand the situation or follow instructions. The client is also restrained and cannot move or escape without assistance. The nurse should evacuate this client first and remove the restraints as soon as possible.
Choice B reason: This is not the correct choice because this client has a moderate risk of injury or death in the event of a fire. The client is postoperative and has a chest tube, which may limit their mobility and require special equipment. However, the client is not confused or restrained and can cooperate with the evacuation process. The nurse should evacuate this client after the confused and restrained client.
Choice C reason: This is not the correct choice because this client has a low risk of injury or death in the event of a fire. The client is in Buck's traction, which is a type of skin traction that does not require pins or wires. The client can be easily moved by releasing the weights and securing the traction to the bed. The nurse should evacuate this client after the postoperative and chest tube client.
Choice D reason: This is not the correct choice because this client has the lowest risk of injury or death in the event of a fire. The client is receiving IV chemotherapy, which is a treatment that can be stopped and resumed later. The client is also ambulatory, which means they can walk and move without assistance. The nurse should evacuate this client last or ask them to evacuate themselves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is a correct statement by the newly licensed nurse. Airborne precautions are used for clients who have infections that can be transmitted through the air, such as tuberculosis, chickenpox, or measles. The nurse should have the client wear a mask when leaving the room to prevent spreading the infection to others.
Choice B reason: This is an incorrect statement by the newly licensed nurse. A negative-pressure airflow room is used for clients who are on airborne precautions, not for clients who have compromised immunity. A negative-pressure airflow room prevents contaminated air from escaping the room and infecting others. A client who has compromised immunity should be placed in a positive-pressure airflow room, which prevents outside air from entering the room and exposing the client to pathogens.
Choice C reason: This is an incorrect statement by the newly licensed nurse. An N95 respirator mask is used for clients who are on airborne precautions, not for clients who are on droplet precautions. Droplet precautions are used for clients who have infections that can be transmitted through respiratory droplets, such as influenza, pertussis, or meningitis. The nurse should wear a surgical mask, not an N95 respirator mask, when caring for a client who is on droplet precautions.
Choice D reason: This is an incorrect statement by the newly licensed nurse. Visitors do not need to wear a mask when visiting a client who is on contact precautions, unless they are in direct contact with the client or the client's environment. Contact precautions are used for clients who have infections that can be transmitted through direct or indirect contact, such as MRSA, VRE, or C. difficile. The nurse should wear gloves and a gown, and perform hand hygiene before and after caring for a client who is on contact precautions.
Correct Answer is C
Explanation
Choice A reason: Using condoms during treatment for chlamydia is important for preventing transmission, but this is not the priority nursing action. The most critical step for the nurse is fulfilling the legal and public health obligation to report the infection to the health department, as chlamydia is a reportable sexually transmitted infection.
Choice B reason: This is not the correct choice because this action is not appropriate for clients who have chlamydia. Chlamydia is caused by bacteria, not viruses, so antiviral creams are ineffective and unnecessary. The nurse should administer the prescribed antibiotics and monitor the client for any adverse reactions or complications.
Choice C reason:Reporting the infection to the local health department is correct. Chlamydia is a reportable disease in all states, and this step ensures proper public health tracking, partner notification, and prevention of further spread. This is a nurse’s responsibility in accordance with infection control and community health regulations.
Choice D reason: This is not the correct choice because this action is not indicated for clients who have chlamydia. Contact precautions are used to prevent the transmission of infections that are spread by direct or indirect contact with the client or their environment. Chlamydia is not spread by contact, but by sexual intercourse. The nurse should use standard precautions, which include hand hygiene and wearing gloves, when caring for the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today