A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

Direct a fire extinguisher at the fire.

Place wet towels along the base of the door.

Turn off any electrical equipment.

Activate the facility's fire alarm.

Answer and Explanation

The Correct Answer is D

A. Direct a fire extinguisher at the fire:

While using a fire extinguisher is an essential action in controlling a small fire, it should come after the fire alarm has been activated. Alerting others to the fire and initiating the emergency response system take precedence to ensure a coordinated and safe response.

B. Place wet towels along the base of the door:

Placing wet towels along the base of the door is a method to help prevent smoke from entering the room. However, in this situation, after ensuring the client's safety, the nurse should focus on activating the facility's fire alarm to alert others and initiate the emergency response.

C. Turn off any electrical equipment:

While turning off electrical equipment is a generally sound practice in fire safety, it is not the immediate next action after moving the client to safety. Activating the fire alarm takes precedence as it initiates a coordinated response and alerts others to the emergency.

D. Activate the facility's fire alarm:

This is the correct action. Activating the fire alarm is a critical step in alerting the entire facility to the presence of a fire. It ensures that emergency response teams are notified promptly, and appropriate measures can be taken to address the fire, including evacuating other occupants and summoning professional firefighting assistance.

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Correct Answer is B

Explanation

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

A. Administer the client's medications one at a time. B. Encourage the client to use a straw to take the medications. C. Give the client's medications between meals. D. Assist the client into semi-Fowler's position.

Correct Answer is A

Explanation

A. Administer the client's medications one at a time:

This is the correct action. Administering medications one at a time allows the nurse to monitor the client's ability to swallow each medication safely. It minimizes the risk of aspiration and ensures that each medication is swallowed effectively.

B. Encourage the client to use a straw to take the medications:

Using a straw may not be recommended for clients with dysphagia, as it can alter the normal swallowing process and increase the risk of aspiration. The focus should be on safe administration of medications without compromising the client's ability to swallow.

C. Give the client's medications between meals:

The timing of medication administration is important, but the priority is the safe administration of medications, especially for clients with dysphagia. Administering medications between meals may not directly address the safety concerns related to swallowing.

D. Assist the client into semi-Fowler's position:

While positioning is important, especially for clients with dysphagia, the administration of medications one at a time (Option A) takes precedence in ensuring the safety of the client's swallowing. Semi-Fowler's position may be beneficial, but it is not the primary action related to medication administration.

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A nurse identifies a small fire in a client's room. After moving the client to safety, which of the following is the next action the nurse should take?

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