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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.

Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.

Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.

Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.

A. Determine client care goals. B. Review the client's new laboratory values. C. Complete required tasks. D. Document assessment data.

Correct Answer is A

Explanation

Choice A reason: This is the first action the nurse preceptor should take to demonstrate appropriate time management. By determining the client care goals, the nurse preceptor can prioritize the most important and urgent tasks for each client and delegate appropriately.

Choice B reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Reviewing the client's new laboratory values is an important task, but it should be done after determining the client care goals and before completing the required tasks.

Choice C reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Completing the required tasks is an essential part of nursing care, but it should be done after determining the client care goals and reviewing the client's new laboratory values.

Choice D reason: This is not the first action the nurse preceptor should take to demonstrate appropriate time management. Documenting the assessment data is a vital part of nursing care, but it should be done after completing the required tasks and before the end of the shift.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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