A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?

Pull the fire alarm panel.

Obtain a fire extinguisher.

Remove the client from the room.

Close the door to the client's room.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not an appropriate action to take first because pulling the fire alarm panel can alert other staff and personnel about the fire and activate the emergency response system, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should pull the fire alarm panel after removing the client from the room.

Choice B reason: This is not an appropriate action to take first because obtaining a fire extinguisher can help extinguish or contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should obtain a fire extinguisher after removing the client from the room.

Choice C reason: This is an appropriate action to take first because removing the client from the room can protect them from smoke inhalation, burns, or injuries and ensure their safety and well-being. The nurse should remove the client from the room as quickly and safely as possible and follow the RACE protocol (Rescue, Alarm, Contain, Extinguish).

Choice D reason: This is not an appropriate action to take first because closing the door to the client's room can help contain the fire and prevent it from spreading to other areas, but it does not address the immediate safety and well-being of the client who is exposed to smoke and flames. The nurse should close the door to the client's room after removing them from the room.

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Correct Answer is B

Explanation

Choice A reason: Taking four nitroglycerin sublingual tablets if having chest pain is an incorrect statement that indicates a lack of understanding of the teaching. Nitroglycerin is a medication that dilates the coronary arteries and relieves angina by improving blood flow to the heart. The client should take one nitroglycerin tablet every 5 minutes for up to three doses if having chest pain. If the pain persists after three doses, the client should call emergency response.

Choice B reason: Notifying emergency response if having sudden jaw pain is a correct statement that indicates an understanding of the teaching. Jaw pain is one of the possible signs of a heart attack, which is a life-threatening condition that occurs when the blood supply to the heart is blocked. Other signs of a heart attack include chest pain, arm pain, shortness of breath, nausea, sweating, or dizziness. The client should seek immediate medical attention if experiencing any of these symptoms.

Choice C reason: Waiting 30 minutes before taking action if having heartburn is an incorrect statement that indicates a lack of understanding of the teaching. Heartburn is a burning sensation in the chest or throat that can be caused by acid reflux, gastritis, or other gastrointestinal disorders. However, heartburn can also mimic or mask angina or a heart attack, especially in women, elderly, or diabetic clients. The client should not ignore or delay seeking help if having chest discomfort that may be related to cardiac problems.

Choice D reason: Having hot, dry, and flushed skin if having a heart attack is an incorrect statement that indicates a lack of understanding of the teaching. Hot, dry, and flushed skin is not a typical sign of a heart attack, but it may indicate fever, dehydration, or allergic reaction. The client should monitor his temperature and hydration status and report any abnormal findings to the provider.

A. Flush the tube with 90 mL of sterile water before and after the feeding. B. Administer the feeding solution at a cold temperature. C. Elevate the head of the client's bed for 1 hour after the feeding. D. Rotate the jejunostomy tube once per day.

Correct Answer is C

Explanation

Choice A reason: Flushing the tube is essential to maintain patency, but the recommended volume is typically 30–60 mL of water before and after feedings or medication administration. Using 90 mL is excessive and could increase the risk of fluid overload, especially in clients with fluid restrictions.

Choice B reason: Administering feeding solutions at a cold temperature can cause discomfort, cramping, and even diarrhea for the patient. It is generally recommended to administer enteral feeding solutions at room temperature to avoid these complications.

Choice C reason: Keeping the head of the bed elevated for at least 30–60 minutes after a feeding reduces the risk of aspiration, even with a jejunostomy tube. While aspiration risk is lower with jejunal feeding compared to gastric feeding, maintaining an upright position still promotes digestion and prevents reflux.

Choice D reason: Rotating the jejunostomy tube is not typically recommended as it can cause irritation and potential dislodgement. The tube should be secured and left in place unless otherwise directed by a healthcare provider.

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A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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