A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

Close the fire doors on the unit

Use a fire extinguisher to put out the fire

Move any clients in the immediate vicinity.

Activate the fire alarm

Answer and Explanation

The Correct Answer is C

A. Close the fire doors on the unit:
Closing fire doors is a safety measure to contain smoke and flames, but activating the fire alarm is the priority to ensure a swift and comprehensive response.

B. Use a fire extinguisher to put out the fire:
While using a fire extinguisher is an important action, it should come after activating the fire alarm. The fire alarm alerts everyone to the emergency, and then the appropriate personnel can use fire extinguishers as needed.

C. Move any clients in the immediate vicinity:

Priority action during a fire: The priority in any fire situation is to ensure the safety of individuals in the immediate area. The acronym RACE is commonly used in healthcare settings to outline the steps to take in the event of a fire:

Rescue anyone in immediate danger.
Alarm: Activate the fire alarm.
Contain the fire by closing doors.
Extinguish the fire if it is small and safe to do so, or Evacuate the area if necessary.

D. Activate the fire alarm
This is also important but comes after rescuing or moving clients in immediate danger.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Suppress respiratory effort
Pancuronium is a neuromuscular blocking agent that is often used to induce paralysis in patients requiring mechanical ventilation. It works by blocking the transmission of nerve impulses at the neuromuscular junction, leading to skeletal muscle paralysis. In the context of a client with acute respiratory distress syndrome (ARDS) on mechanical ventilation, the use of pancuronium helps to suppress respiratory effort, allowing for better control of the patient's ventilation and oxygenation.

B. Decrease chest wall compliance:
Pancuronium does not directly affect chest wall compliance. It primarily acts on skeletal muscles, leading to paralysis.

C. Decrease respiratory secretions:
Pancuronium is not used to decrease respiratory secretions. It is a neuromuscular blocking agent with the main goal of inducing paralysis.

D. Induce sedation:
Pancuronium does not induce sedation. It works on the neuromuscular junction and does not have sedative properties. Sedation may be achieved with other medications, such as sedative agents.

A. Decreased lung sounds B. Heart rate 110/min and regular C. Oxygen saturation of 95% D. Subcutaneous emphysema E. Trachea midline F. Puncture site dry

Correct Answer is ["A","D"]

Explanation

A. Decreased lung sounds
A decrease in lung sounds could indicate a pneumothorax, which is a potential complication of thoracentesis. It requires prompt evaluation.

B. Heart rate 110/min and regular
A heart rate of 110/min is within a normal range, and regular rhythm is generally acceptable post-thoracentesis. It may be related to pain or anxiety but is not an immediate concern.

C. Oxygen saturation of 95%
An oxygen saturation of 95% is within an acceptable range. While maintaining adequate oxygenation is important, this finding does not suggest an immediate complication.

D. Subcutaneous emphysema
Subcutaneous emphysema involves the presence of air in the subcutaneous tissues and can indicate a communication between the pleural space and subcutaneous tissues. This requires immediate attention.

E. Trachea midline
The trachea being midline is a normal finding and does not indicate an immediate problem post-thoracentesis.

F. Puncture site dry
A dry puncture site is expected after a thoracentesis. This finding is normal and indicates appropriate wound care. It is included in the list to ensure recognition of normal post-procedure findings.

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A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Correct Answer is A

Explanation

The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

Correct Answer is ["A","D"]

Explanation

A nurse is teaching a class on leadership. The nurse should include that which of the following types of leaders strictly enforce rules to maintain compliance?

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings?

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?