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

The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.

A. "These exercises prevent thrombophlebitis." B. "The doctor ordered the exercises." C. "These exercises help prevent pneumonia." D. "All surgical clients must do these exercises." E. The correct answer and explanation is:

Correct Answer is C

Explanation

Turning, deep breathing, and coughing exercises are important for clients recovering from surgery as they help prevent the development of pneumonia. After surgery, clients may have difficulty taking deep breaths and coughing due to pain or discomfort. This can lead to the accumulation of mucus in the lungs, increasing the risk of pneumonia. By performing these exercises, clients can help clear their lungs and reduce their risk of developing this complication. While these exercises may also help prevent other complications such as thrombophlebitis, the primary reason for performing them is to prevent pneumonia.

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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

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Correct Answer is C

Explanation

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. How should the nurse respond?

Correct Answer is C

Explanation

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

A client is hospitalized with numerous acute health problems. According to Maslow's hierarchy of needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?

Which one of the following roles of the home health care nurse illustrates the role of coordinator of services?

A client with a terminal illness without an advance directive stops breathing and does not have a heartbeat. What should the nurse do?

A client has been prescribed a clear liquid diet. What food or ﬂuids will be served?

The nurse instructs the client on mind-body therapies. Which mind-body therapy is used when the client pictures themselves lying on a beach with the sounds of waves, the cries of seagulls, and the warmth of the sun during periods of stress?

A nurse is conducting a lung assessment on a client suspected of having pneumonia. Which finding should the nurse report to the physician immediately?

The nurse has been caring for a client for several days and has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake?