A nurse is providing an in-service about client evacuation during a fire.

Which of the following clients should the nurse instruct the staff to evacuate first?

A client who is ambulatory and receiving oxygen.

A client who uses a wheelchair and is confused.

A client who is bedridden and wears a hearing aid.

A client who has a fracture and is in balance suspension traction.

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Answer and Explanation

The Correct Answer is A

The correct answer is choice A. A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.

Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.

Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.

Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.

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Correct Answer is D

Explanation

The correct answer is choice D. Administer a cathartic suppository 30 min prior to scheduled defecation times. This is because a cathartic suppository stimulates the nerve endings in the rectum, causing a contraction of the bowel and facilitating defecation. This is especially helpful for clients who have an upper motor neuron or reflexic bowel, which means they have lost the ability to feel when the rectum is full and have a tight anal sphincter muscle. A

bowel program is a way of controlling or moving the bowels after a spinal cord injury, which may affect normal bowel function depending on the spinal level involved. A bowel program aims to achieve regular bowel movements, prevent constipation or impaction, and avoid accidents.

Choice A is wrong because encouraging a maximum fluid intake of 1,500 mL per day is not enough to prevent constipation and promote bowel health. A fluid intake of at least 2,000 mL per day is recommended for most adults.

Choice B is wrong because increasing the amount of refined grains in the client’s diet can worsen constipation and reduce stool bulk.

Refined grains are low in fiber, which is essential for normal bowel function. A high-fiber diet of at least 20 to 35 grams per day is advised for clients with spinal cord injury.

Choice C is wrong because providing the client with a cold drink prior to defecation can have the opposite effect of stimulating the bowel.

Cold drinks can slow down the digestive process and reduce peristalsis, which is the movement of food through the intestines. Warm or hot drinks can help stimulate the bowel and increase peristalsis.

A. Beneficence. B. Fidelity. C. Autonomy. D. Veracity.

Correct Answer is A

Explanation

The correct answer is A. Beneficence. Beneficence is the ethical principle of doing good for the patient and promoting their well-being.

The nurse is demonstrating beneficence by sitting with the client to provide comfort and support during a difficult time.

Choice B is wrong because fidelity is the ethical principle of keeping promises to the patient and being loyal and faithful.

The nurse is not making or keeping any promises to the client in this scenario.

Choice C is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own decisions and choices.

The nurse is not interfering with the client’s autonomy in this scenario.

Choice D is wrong because veracity is the ethical principle of telling the truth to the patient and being honest and trustworthy.

The nurse is not lying or withholding information from the client in this scenario.

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A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

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A nurse is providing an in-service about client evacuation during a fire.

Which of the following clients should the nurse instruct the staff to evacuate first?