A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions should the nurse include in the teaching?

Open nearby doors and windows when the fire alarm sounds

Attempt to extinguish the fire before evacuating clients.

Have ambulatory clients walk independently to a safe location

Aim the spray of the fire extinguisher at the top of the fire.

Answer and Explanation

The Correct Answer is C

A. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.

B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.

C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.

D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.

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Correct Answer is C

Explanation

A. Serosanguinous drainage on dressing: Serosanguinous drainage, which is a mixture of clear and blood-tinged fluid, is a common and expected finding in the early postoperative period. It typically indicates normal healing unless the amount becomes excessive or the drainage changes character.

B. Hypoactive bowel sounds: Hypoactive bowel sounds are common within the first 24 to 48 hours following surgery, especially after general anesthesia or abdominal procedures. This finding is expected and does not immediately require provider notification unless accompanied by other concerning signs like severe abdominal distention.

C. Urinary output of 25 mL/hr: Urinary output should be at least 30 mL/hr to indicate adequate kidney perfusion and hydration. An output of 25 mL/hr suggests possible hypovolemia, renal impairment, or urinary retention, and it should be promptly reported to the provider for further evaluation.

D. Pain level of 2 on 0 to 10 scale: A pain score of 2 indicates mild pain, which is manageable and expected after surgery. This level of discomfort does not require urgent reporting to the provider as long as it remains controlled and does not interfere with recovery activities.

A. Document an incident report in a client's medical record. B. Notify the provider if a client fails C. Assist with the care of a client who has fallen. D. Collect data about each fall

Correct Answer is D

Explanation

A. Document an incident report in a client's medical record: Incident reports are essential for internal documentation but should not be placed in the client’s medical record. Including them in the medical record can lead to legal complications. This action addresses individual events rather than contributing to systematic quality improvement efforts.

B. Notify the provider if a client falls: Notifying the provider about a fall is a necessary clinical step to ensure immediate evaluation and care for the client. However, simply informing the provider does not contribute directly to a quality improvement initiative aimed at analyzing and reducing overall fall rates.

C. Assist with the care of a client who has fallen: Providing immediate care after a fall is crucial to ensure client safety and manage injuries. However, assisting after the fall focuses on acute clinical response rather than on proactive measures to identify trends and reduce the incidence of future falls.

D. Collect data about each fall: Collecting data is a fundamental part of quality improvement projects. By systematically gathering information on when, where, and how falls occur, patterns can be identified, leading to the development of targeted interventions aimed at preventing future incidents.

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A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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