A nurse enters a client's room and sees smoke coming from a wall outlet.
After removing the client from the room, which of the following actions should the nurse take next?
Close the door to the client's room.
Report the fire details to the facility emergency extension.
Activate the fire alarm.
Turn off electrical equipment.
The Correct Answer is A
Choice A rationale
Closing the door prevents the spread of smoke and fire to other areas, protecting clients and staff. This action aligns with the RACE (Rescue, Alarm, Contain, Extinguish) protocol to contain fire hazards effectively while prioritizing safety.
Choice B rationale
Reporting fire details is crucial but should occur after ensuring client safety and containment of the fire. Early containment by closing the door prevents escalation, reducing the risk of harm to others in the facility.
Choice C rationale
Activating the fire alarm is important; however, containment actions such as closing the door take precedence to manage the immediate fire hazard. Containment minimizes risks while allowing subsequent emergency actions to occur.
Choice D rationale
Turning off electrical equipment is important but secondary in prioritization. Containing the fire’s spread by closing the door first ensures broader safety for all. Electrical disconnection can follow once the immediate hazard is managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Autonomy supports the client’s decision-making capacity, allowing them to determine their care preferences, including discontinuing enteral feedings. Respecting autonomy aligns with ethical nursing practice, prioritizing the client’s informed choices and independence.
Choice B rationale
Fidelity relates to maintaining commitments and professional promises but does not directly address respecting client decisions regarding care. While trust is essential, autonomy is more applicable in this context.
Choice C rationale
Justice emphasizes fairness and equal treatment, which is vital in resource distribution and ethical practice. However, it does not directly pertain to honoring a client’s individual decisions.
Choice D rationale
Beneficence involves promoting the client’s well-being, which might conflict with their decision to discontinue treatment. Supporting autonomy takes precedence when clients make informed choices. .
Correct Answer is C
Explanation
Choice A rationale
Reporting pain as 8 on a scale of 0 to 10 indicates significant discomfort and may require analgesic adjustments. However, pain alone, without accompanying complications, does not constitute the highest priority in postoperative care.
Choice B rationale
Urinary output of 30 mL over 1 hour is below the normal adult range of 30–50 mL/hour, potentially indicating hypovolemia or renal issues. However, it does not outweigh circulatory concerns like leg mottling as the most immediate threat.
Choice C rationale
Mottling in the affected leg suggests compromised circulation, possibly due to a blood clot or arterial occlusion, which can lead to tissue ischemia. Immediate intervention is necessary to prevent irreversible damage or complications like necrosis.
Choice D rationale
Postoperative emesis can lead to dehydration and electrolyte imbalances if persistent. However, it does not pose the same urgent threat as vascular compromise seen in mottling of the affected leg.
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