A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

Use a fire extinguisher at the source of the smoke.

Close the doors to the room and to the bathroom.

Activate the fire alarm system.

Assist the client to a nearby common area.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Using a fire extinguisher at the source of the smoke is not appropriate. While using a fire extinguisher could potentially help contain a small fire, it's crucial to prioritize rescuing those in immediate danger and alerting others about the fire first by activating the fire alarm. This action ensures that help is on the way and that everyone is aware of the emergency.
Choice B Reason:
Closing the doors to the room and to the bathroom is not appropriate. Closing doors can help contain smoke and fire to some extent, but again, the priority in an emergency situation like this is to rescue those in immediate danger then activate the fire alarm to ensure a swift response and alert others.
Choice C Reason:
Activate the fire alarm system is appropriate. Activating the fire alarm alerts others in the facility and initiates the emergency response protocol, helping to ensure that help is on the way while potentially preventing the spread of fire. However, this step should be taken after assisting the client to safety as they are in immediate danger.
Choice D Reason:
Assisting the client who is in immediate danger to a nearby common area should be the furst step that the nurse takes before alerting other people of the fire. (RACE protocol)

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Correct Answer is A

Explanation

Choice A Reason:

The client's fingers are cool to the touch is correct. Coolness of the fingers within a short time after a cast application can indicate compromised circulation or potential compartment syndrome, which requires urgent attention to prevent tissue damage or loss of function. It suggests impaired blood flow to the fingers, which is a serious concern requiring immediate evaluation by the provider.

Choice B Reason:

The client reports severe itching under the cast is incorrect. While itching can be uncomfortable, it might not pose an immediate threat. Itching can commonly occur as the skin heals and can be managed through non-invasive means.

Choice C Reason:

The client's capillary refill is 3 seconds is incorrect. A capillary refill of 3 seconds is slightly prolonged but doesn't typically indicates an immediate emergency. However, if this finding worsens or if combined with other concerning symptoms, it might warrant further assessment.

Choice D Reason:

The client reports increased pain at the area of the fracture is incorrect. Increased pain after a cast application can be expected initially, especially within 2 hours of the procedure. However, persistent or severe pain could indicate issues like poor alignment, swelling, or other complications. While it's important to address pain, it might not require immediate reporting unless accompanied by other concerning symptoms.

A. Temperature 37.3° C (99.1° F) B. Changed mental status C. WBC count 9,000/mm3 (5000 to 10,000/mm3) D. Diminished reflexes

Correct Answer is B

Explanation

Choice A Reason:

Temperature 37.3°C (99.1°F) is incorrect . While a slightly elevated temperature can sometimes accompany an infection, it's not specific to a bladder infection and might not be present in all cases.

Choice B Reason:

Changed mental status is incorrect. Bladder infections or urinary tract infections (UTIs) in older adults can often present with atypical symptoms, and changes in mental status or acute confusion are common indicators in this population. UTIs can cause subtle but significant alterations in mental function, particularly in the elderly, leading to confusion, agitation, or cognitive impairment.

Choice C Reason:

WBC count 9,000/mm3 (5000 to 10,000/mm3) is incorrect .A WBC count within the normal range doesn't necessarily rule out or confirm a bladder infection. In some cases, UTIs might not significantly elevate the white blood cell count, especially in localized infections.

Choice D Reason:

Diminished reflexes is incorrect . Diminished reflexes are not typically associated with a bladder infection. They might indicate other neurological or muscular issues but are not a common sign of a UTI.

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A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who had a long arm cast applied 2 hr. ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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