A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Close the window and remove the client’s oxygen.

Sound the fire alarm and activate the emergency response system.

Cover the client with a blanket to smother the flames.

Remove the client from the room and close the door.

Answer and Explanation

The Correct Answer is C

This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.

This will also help contain the fire and prevent it from spreading.

Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.

Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.

Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.

Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.

The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.

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Correct Answer is B

Explanation

This outcome indicates that the client has resolved their constipation and has a regular pattern of defecation without difficulty or discomfort.

Choice A is wrong because taking a laxative daily can worsen constipation by causing dependency and reducing the natural peristalsis of the colon.

Choice C is wrong because requesting a bedpan every four hours does not necessarily mean that the client has bowel movements. It may indicate that the client has difficulty passing stool or has a sensation of incomplete emptying.

Choice D is wrong because having a bowel movement within 72 hours is still considered constipation. Constipation is diagnosed when bowel movements are associated with at least two of the following symptoms, occurring in the past three months with an onset of symptoms of at least six months: Less than three spontaneous bowel movements per week, Lumpy or hard stools from at least 25% of bowel movements.

A. Apply warm soaks to reduce the inflammation. B. Notify the health care provider immediately of the infection. C. Place the client on contact (wound) precautions. D. Document the findings and continue to monitor the wound.

Correct Answer is D

Explanation

. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can

cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.

These are normal signs of wound healing and do not indicate infection or complications.

Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.

Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.

Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.

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A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which outcome is expected for a client who has a diagnosis of constipation? The client:.

Correct Answer is B

Explanation

Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Correct Answer is D

Explanation

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