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

Activate the fire alarm.

Move any clients in the immediate vicinity.

Close the fire doors on the unit.

Use a fire extinguisher to put out the fire.

Answer and Explanation

The Correct Answer is A

A) Activate the fire alarm: The nurse's priority in the event of a fire is to activate the fire alarm immediately. This alerts others in the building, including staff and emergency responders, to the potential danger. It initiates the necessary protocol to ensure the safety of all individuals in the area and enables timely evacuation if needed. Ensuring that others are aware of the fire risk is the first critical step in managing the situation effectively.

B) Move any clients in the immediate vicinity: While moving clients away from the immediate danger is important, it should come after the alarm has been activated. The fire alarm alerts everyone to evacuate or take necessary precautions, allowing the nurse and other staff to focus on evacuation or safety measures. The priority is to ensure that everyone is aware of the potential fire hazard and follows the evacuation procedures.

C) Close the fire doors on the unit: Closing fire doors is part of fire containment, but it should occur after the alarm has been activated and the fire response plan is in motion. Fire doors are designed to limit the spread of fire, but the initial priority is to alert others to the fire, activate the alarm, and ensure everyone is aware of the emergency situation.

D) Use a fire extinguisher to put out the fire: Using a fire extinguisher is appropriate if the fire is small and manageable, but activating the fire alarm is still the first priority. In cases of small fires, if safe to do so, the nurse can attempt to put it out. However, the primary focus should be on alerting everyone in the facility to the danger so that emergency protocols can be followed.

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Correct Answer is B

Explanation

A) Return any fresh linen not used for a client to the linen supply: Fresh linen that has been placed on a client’s bed but not used should not be returned to the linen supply. This is to prevent cross-contamination. Once linen is brought into a patient’s room, it should be considered contaminated, even if it was not used, and should be discarded properly.

B) Tie linen bags securely at the top: This is the correct action. When disposing of soiled linens, tying the linen bag securely helps to prevent the spread of pathogens and minimizes the risk of contamination. It also keeps the environment clean and safe for both staff and patients.

C) Fill linen bags with as much soiled linen as possible: Linen bags should not be overfilled. Overfilling bags can make them difficult to handle and can increase the risk of exposure to contaminants. Bags should be filled to a safe and manageable level to ensure proper handling and safety when transporting soiled linens.

D) Use double bagging to remove soiled linen from the client's room: Double bagging is typically not necessary unless there is a significant risk of contamination, such as with highly infectious material. Standard practice is to use a single, securely tied bag. Double bagging can create unnecessary waste and complicate disposal procedures unless specifically indicated by the situation or facility protocols.

A. Try to do as much as possible for the patient. B. Encourage dairy products. C. Monitor intake of calcium D. increase intake of caffeinated drinks.

Correct Answer is C

Explanation

A) Try to do as much as possible for the patient:
While it's important to provide support to a patient with osteoporosis, especially when they are at risk of fractures, the nurse should focus on empowering the patient to maintain as much independence as possible. Over-involvement in their care may limit their ability to maintain or improve mobility and self-care abilities. The priority is addressing nutritional needs and bone health.

B) Encourage dairy products:
While dairy products are an excellent source of calcium, this approach is not suitable for a patient with lactose intolerance. Consuming dairy could lead to discomfort and digestive issues such as bloating, cramps, and diarrhea, which can worsen the patient's symptoms. Alternative sources of calcium should be recommended instead.

C) Monitor intake of calcium:
This is the most appropriate intervention. Monitoring the patient's calcium intake is crucial for individuals with osteoporosis to help strengthen bones and prevent fractures. The nurse can recommend calcium-rich foods that are lactose-free, such as fortified plant-based milks, leafy green vegetables, and fortified cereals. Calcium supplements may also be necessary to meet the daily requirements.

D) Increase intake of caffeinated drinks:
Increasing caffeinated drinks is not advisable for a patient with osteoporosis, as excessive caffeine consumption can interfere with calcium absorption and contribute to bone loss. It is best to limit caffeine intake and focus on promoting good nutritional habits to support bone health.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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