The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Call the hospital operator to determine if this is indeed a real emergency or a fire drill.

Instruct the clients' family members to stay in the visitor waiting area until further notice.

Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner.

Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.

Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.

Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.

Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.

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Correct Answer is B

Explanation

Choice A Reason: Beginning initial sterile wound care for surgical clients is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The PN may assist with wound care after the initial dressing change, but the RN is responsible for assessing the wound and initiating the plan of care.

Choice B Reason: Validating prescribed intravenous flow rates is a routine task that does not require clinical judgment and can be delegated to the PN. The PN has the knowledge and skill to check the IV orders, calculate the drip rate, and monitor the infusion.

Choice C Reason: Determining the need for urinary catheterizations is a nursing assessment that requires clinical judgment and cannot be delegated to the PN. The PN may perform urinary catheterizations as ordered by the physician, but the RN is responsible for evaluating the indication, risk, and benefit of the procedure.

Choice D Reason: Receiving a postoperative client and conducting the assessment is a nursing intervention that requires clinical judgment and cannot be delegated to the PN. The RN is responsible for receiving reports from the operating room, assessing the client's status, identifying potential complications, and initiating the plan of care.

A. Administered two medications to the same client at the wrong time. B. Documented data in the clinical record before assessing client's condition. C. Served a diet tray to a client who was NPO for a scheduled procedure. D. Changed work assignments without prior approval from charge nurse.

Correct Answer is B

Explanation

Choice A Reason: This is not the best action because it is a medication error that can be corrected and prevented by following the rights of medication administration. The nurse manager should counsel the staff nurse and provide education on safe medication practices.

Choice B Reason: This is the best action because it is a serious breach of professional ethics and standards. The nurse manager should report the staff nurse to the PRC for falsifying documentation and compromising client care.

Choice C Reason: This is not the best action because it is a mistake that can be rectified by removing the diet tray and notifying the healthcare provider. The nurse manager should reprimand the staff nurse and review the policy on NPO status.

Choice D Reason: This is not the best action because it is a minor issue that can be resolved by communicating with the charge nurse and other staff members. The nurse manager should remind the staff nurse of the importance of teamwork and collaboration.

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The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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