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A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance. Use all the steps.)

Transport the client to another area of the nursing unit.

Activate the facility's fire alarm system.

Close all nearby windows and doors.

Use the unit's fire extinguisher to attempt to put out the fire.

Answer and Explanation

The Correct Answer is A,B,C,D

The correct sequence follows the RACE protocol for fire safety:

A. Transport the client to another area of the nursing unit (R: Rescue). Rescue anyone in immediate danger.

B. Activate the facility's fire alarm system (A: Alarm). Activate the alarm system.

C. Close all nearby windows and doors (C: Contain). Contain the fire by closing doors and windows.

D. Use the unit's fire extinguisher to attempt to put out the fire (E: Extinguish). Extinguish the fire if it is safe to do so.

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Correct Answer is B

Explanation

A. A chest x-ray is important to assess pneumonia but is not the priority when chest pain suggesting a cardiac event is present.

B. A 12-lead ECG is the priority to assess for myocardial ischemia or infarction, given the client’s description of chest pain.

C. Serum potassium is important for cardiac health but not the immediate priority in this scenario.

D. PT and INR are relevant for coagulation but do not address the immediate concern of potential myocardial infarction.

A. Protect the IV bag from exposure to light. B. Keep calcium gluconate at the client's bedside. C. Attach an inline filter to the IV tubing. D. Monitor blood pressure every 2 hr.

Correct Answer is A

Explanation

A. Protect the IV bag from exposure to light: Nitroprusside is light-sensitive and degrades when exposed to light, reducing its potency and effectiveness. It must be protected with an opaque covering.

B. Keep calcium gluconate at the client’s bedside: Incorrect. Calcium gluconate is used to treat hyperkalemia or calcium imbalances, not for nitroprusside administration.

C. Attach an inline filter to the IV tubing: Incorrect. An inline filter is not typically required for nitroprusside.

D. Monitor blood pressure every 2 hr: Incorrect. Continuous or frequent monitoring (every 5-15 minutes) is necessary due to the rapid effects of nitroprusside on blood pressure.

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A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the following is the priority diagnostic test?

Correct Answer is B

Explanation

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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