A nurse enters a client's room and sees smoke coming from the client's trash can.
Which of the following actions should the nurse take first?
Confine the fire by closing doors and windows.
Activate the fire alarm system.
Extinguish the fire if possible.
Rescue the client from immediate danger.
The Correct Answer is D
Choice A rationale:
Confine the fire by closing doors and windows. While confining the fire is important, the nurse's first priority should be ensuring the safety of the client. Closing doors and windows may help prevent the fire from spreading, but it does not address the immediate danger to the client.
Choice B rationale:
Activate the fire alarm system. Activating the fire alarm is a crucial step to alert other staff members, patients, and visitors about the fire. However, it is not the first action the nurse should take. Ensuring the safety of the client should be the top priority.
Choice C rationale:
Extinguish the fire if possible. Attempting to extinguish the fire can be dangerous for the nurse and may waste precious time. The nurse's safety and the client's safety should be the primary concern. Trying to put out the fire before ensuring the client's safety is not the best course of action.
Choice D rationale:
Rescue the client from immediate danger. This is the correct answer because the nurse's first priority in a fire emergency is to ensure the safety of the client. Rescuing the client from immediate danger should be done before any other actions are taken. The nurse should assess the situation, help the client to safety, and then notify others about the fire and activate the alarm system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
An oral temperature of 100°F (37.8°C) is within the normal range for body temperature, which typically ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C) While it's essential to monitor temperatures, this value does not require immediate attention.
Choice B rationale:
A respiratory rate of 30/min is a concerning finding. The normal respiratory rate for adults at rest is typically between 12 to 20 breaths per minute. A rate of 30/min suggests tachypnea (rapid breathing), which can be a sign of various underlying medical issues, including respiratory distress or metabolic acidosis. This requires immediate attention and further assessment.
Choice C rationale:
A radial pulse of 45 beats in 30 seconds can be translated to a pulse rate of 90 beats per minute, which falls within the normal range for adults (60 to 100 beats per minute) While it's important to monitor pulse rates, this value does not require immediate attention.
Choice D rationale:
A blood pressure of 114/74 mmHg is within the normal range for blood pressure in adults. Normal blood pressure typically ranges around 120/80 mmHg, but variations within a few points are considered normal. This blood pressure reading does not require immediate attention.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Using a fire extinguisher is part of containment, but it follows evacuation. Attempting to extinguish before removing clients violates RACE protocol and risks patient injury from smoke or electrical fire.
Choice B rationale: Activating the fire alarm initiates emergency response but comes after client rescue. Per RACE (Rescue, Alarm, Contain, Extinguish), client safety is prioritized before system-wide alerts.
Choice C rationale: Moving clients to safety is the first step in fire response. It aligns with the “Rescue” phase of RACE, ensuring immediate protection from smoke inhalation, electrical hazards, and fire spread.
Choice D rationale: Confine by closing doors and windows is part of containment, which follows rescue and alarm activation. It helps limit fire spread but is not the initial priority in patient-centered emergencies.
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