A nurse at a long-term care facility discovers flames coming from a trash can in the day room. Which of the following actions should the nurse take first?

Close the doors leading to the area of the fire.

Activate the fire alarm to alert the fire department.

Move the clients to an area of safety.

Use a fire extinguisher to put out the fire.

Answer and Explanation

The Correct Answer is B

Rationale:

A. This option is incorrect because, while closing doors can help contain a fire and reduce the spread of smoke, it is not the first action. Immediate notification is crucial to ensure that professional responders are aware of the fire.

B. This option is correct because activating the fire alarm is the first step in the RACE (Rescue, Alarm, Confine, Extinguish) protocol. Alerting the fire department and facility staff ensures a rapid response, helps coordinate evacuation, and mobilizes additional resources to manage the fire safely.

C. This option is incorrect because moving clients to safety is essential, but it follows activating the alarm. Rescue efforts should be coordinated after the fire department is notified to prevent additional hazards during evacuation.

D. This option is incorrect because using a fire extinguisher may be appropriate for a small, contained fire, but it should only be attempted after the alarm has been activated and if it is safe for the nurse to do so. The priority is alerting others to the danger first.

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Correct Answer is B

Explanation

Rationale:

A. This option is incorrect because decreased oxygen saturation reflects a respiratory problem, such as hypoventilation, atelectasis, or pneumonia, rather than an issue with gastrointestinal function. While low oxygen saturation is clinically significant and requires intervention, it does not indicate a need for nasogastric (NG) tube insertion.

B. This option is correct because abdominal distention after an open appendectomy is a common sign of postoperative ileus or gastric outlet obstruction, both of which can lead to accumulation of gas and fluid in the stomach and intestines. A nasogastric tube with low intermittent suction can decompress the stomach, reduce pressure and discomfort, prevent nausea and vomiting, and lower the risk of complications such as aspiration or wound dehiscence. Early recognition and intervention are essential for client safety and comfort.

C. This option is incorrect because decreased bowel sounds are expected in the first several hours after abdominal surgery due to anesthesia and handling of the intestines. While it signals the need for continued monitoring, it alone does not require NG tube placement. Clinical decisions should consider the combination of symptoms, such as distention, nausea, vomiting, and pain.

D. This option is incorrect because incisional pain is an expected postoperative finding and is managed with analgesics, positioning, and non-pharmacological methods. Pain alone does not indicate gastrointestinal obstruction or the need for NG suction.

A. the nurse organized client care activities based on priority B. Nurse observed gathering all necessary supplies before inserting a client's peripheral IV C. Client care activities are grouped based on their location within the unit D. Documentation of client assessments performed at the end of the nursing shift

Correct Answer is ["A","B","C"]

Explanation

Rationale

Organized client care activities based on priority: Prioritizing care at the beginning of the shift demonstrates effective planning and ensures that the most critical client needs are addressed first.
Observed gathering all necessary supplies before inserting a client's peripheral IV: Collecting supplies before starting a procedure prevents unnecessary interruptions and improves efficiency.
Client care activities are grouped based on their location within the unit: Clustering care by location reduces wasted time and unnecessary movement, supporting effective time management.
Documentation of client assessments performed at the end of the nursing shift: Delaying documentation until the end of the shift is inefficient and may compromise accuracy; documentation should be completed as close to the time of care as possible.

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A nurse at a long-term care facility discovers flames coming from a trash can in the day room. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 4 hr postoperative following an open appendectomy. Which of the following manifestations should indicate to the nurse that the client requires a nasogastric tube with low intermittent suction?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C"]

Explanation

A nurse manager is performing a record audit as part of the unit's quality improvement program. The nurse should identify that which of the following examples demonstrates the correct use of approved abbreviations in a medical record?

A charge nurse is following up on a task delegated to another nurse and discovers an error that could harm the client. Which of the following actions should the charge nurse take?

A nurse is planning care after receiving reports for four clients. Which of the following clients should the nurse plan to assess first?

A nurse manager witnesses an assistive personnel (AP) using incorrect procedure when transferring a client using a mechanical lift. After reinforcing proper procedure, which of the following methods should the nurse manager use to evaluate the AP's understanding of the teaching?

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A nurse is planning interdisciplinary care for a client experiencing an exacerbation of myasthenia gravis. Which of the following information should the nurse plan to communicate to an occupational therapist?