A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
Close the fire doors and the doors to the clients' rooms.
Activate the fire alarm.
Extinguish the fire.
Remove all clients from the unit.
The Correct Answer is B
Choice A reason: Closing the fire doors and the doors to the clients' rooms is an action that the nurse should take after activating the fire alarm, as it helps to contain the fire and prevent smoke inhalation.
Choice B reason: Activating the fire alarm is the first action that the nurse should take after removing the client from the room, as it alerts the fire department and the rest of the staff and clients about the fire.
Choice C reason: Extinguishing the fire is an action that the nurse should take only if the fire is small and confined, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should use the appropriate fire extinguisher and follow the PASS technique (pull, aim, squeeze, sweep).
Choice D reason: Removing all clients from the unit is an action that the nurse should take only if the fire is large and spreading, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should follow the RACE protocol (rescue, alarm, confine, extinguish/evacuate) and the facility's emergency plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This client does not need an interdisciplinary conference because their condition is not complex or chronic. The nurse can manage the client's care by monitoring their vital signs, fluid intake and output, and hydration status. The nurse can also educate the client on how to prevent orthostatic hypotension by changing positions slowly and wearing compression stockings.
Choice B reason: This client does not need an interdisciplinary conference because their condition is well-controlled and self-managed. The nurse can manage the client's care by checking their blood glucose levels, administering insulin as prescribed, and providing dietary and lifestyle education. The nurse can also collaborate with the diabetes educator or the endocrinologist if needed.
Choice C reason: Although this client is at risk for pressure ulcers, their albumin level is within the normal range, indicating adequate nutritional status. Low albumin levels are often associated with poor wound healing and increased risk of skin breakdown, but in this case, nutrition does not appear to be a concern. Preventive measures, such as regular repositioning, skin assessments, and pressure-relieving devices, can be implemented by nursing staff without requiring an interdisciplinary meeting.
Choice D reason:This client is the most appropriate candidate for an interdisciplinary conference. The activated partial thromboplastin time (aPTT) is a critical lab value for monitoring heparin therapy, and a level of 34 seconds is below the therapeutic range. A subtherapeutic aPTT increases the risk of clot formation, indicating that the heparin dose may need to be adjusted. An interdisciplinary team, including the physician, pharmacist, nurse, and laboratory personnel, should collaborate to ensure safe and effective anticoagulation management. This conference would allow for a discussion on dosage adjustments, potential medication interactions, and continued monitoring to prevent complications such as deep vein thrombosis or pulmonary embolism.
Correct Answer is D
Explanation
Choice A reason: The most recent blood glucose reading is not the most important information for the nurse to report at shift change. IV corticosteroids can cause hyperglycemia, which requires monitoring and treatment, but it is not as critical as the client's level of consciousness.
Choice B reason: The laboratory tests scheduled for next shift are not the most important information for the nurse to report at shift change. The nurse should inform the oncoming nurse about the tests, but they are not as urgent as the client's neurological status.
Choice C reason: The reddened area on the coccyx is not the most important information for the nurse to report at shift change. The nurse should document and report any signs of skin breakdown, but they are not as life-threatening as the client's increased intracranial pressure.
Choice D reason: The Glasgow Coma Scale score is the most important information for the nurse to report at shift change. The Glasgow Coma Scale is a tool that measures the client's level of consciousness based on eye opening, verbal response, and motor response. A decrease in the score indicates a deterioration in the client's neurological condition, which requires immediate intervention.
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