A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Extinguish the fire if possible.

Rescue the client from immediate danger.

Activate the fire alarm system.

Confine the fire by closing doors and windows.

Answer and Explanation

The Correct Answer is B

The first action the nurse should take in this situation is to rescue the client from immediate danger. This means ensuring that the client is safely removed from the room and away from the fire. The safety of the client is the top priority in this situation. Once the client is safe, the nurse can then take further actions such as activating the fire alarm system and attempting to extinguish the fire if possible.

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Correct Answer is C

Explanation

A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.

A. "Oh, for gosh sakes. it doesn't look that bad." B. "I understand, but you are going to have to look someday." C. "Respect your wish not to look at it right now." D. "You won't be able to go home until you look at it."

Correct Answer is C

Explanation

The appropriate response by the nurse in this situation would be to respect the young man's wish not to look at the wound during dressing changes. This response shows empathy and understanding toward the patient's feelings and emotions and allows him to have control over his own care. It is important for healthcare providers to respect their patient's autonomy and decisions regarding their own care.

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A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Correct Answer is C

Explanation

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

Correct Answer is C

Explanation

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