The nurse is caring for a client on the medical unit when the waste basket catches fire. What is the priority action for the nurse?

Contain the fire by closing all the doors.

Extinguish the fire by using the nearest fire extinguisher.

Remove the client from immediate danger.

Activate the fire alarm.

Answer and Explanation

The Correct Answer is C

Choice A reason: Containing the fire by closing all the doors is an important step to prevent the spread of fire and smoke, but it is not the priority action. The primary concern should be the safety of the client, which involves removing them from immediate danger.

Choice B reason: Extinguishing the fire using the nearest fire extinguisher is a critical action to control the fire, but it should not take precedence over ensuring the client's safety. The nurse must first ensure that the client is out of harm's way before attempting to put out the fire.

Choice C reason: Removing the client from immediate danger is the priority action. The nurse's first responsibility is to ensure the safety of the client by getting them to a safe area away from the fire. This action minimizes the risk of injury or harm to the client.

Choice D reason: Activating the fire alarm is essential to alert other staff and initiate emergency procedures, but it should be done after ensuring that the client is safe. The primary focus should be on the immediate safety of the client, followed by actions to manage the fire.

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Correct Answer is B

Explanation

Choice A reason: The yellow category in the START triage system is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. Since this client is ambulatory, she does not fit into the yellow category.

Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is awake, alert, oriented, and able to follow commands, indicating that she is stable and her injuries are not life-threatening.

Choice C reason: The black category is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is stable and responsive, so she does not fit into this category.

Choice D reason: The red category is for clients who need immediate life-saving intervention. Although this client has a headache and neck pain, her vital signs and ability to follow commands indicate that she does not require immediate life-saving intervention.

A. "Taking estrogen as prescribed will help to decrease the growth of facial hair." B. "Taking estrogen as prescribed may increase my risk for migraine headaches." C. "Taking estrogen as prescribed will help to decrease my body's muscle mass." D. "Taking estrogen as prescribed may cause infertility."

Correct Answer is A

Explanation

Choice A reason: This statement is incorrect because estrogen therapy may not effectively reduce the growth of facial hair in transgender women. Additional treatments, such as laser hair removal or electrolysis, may be needed to address facial hair growth.

Choice B reason: This statement is correct because estrogen therapy can increase the risk of migraine headaches in some individuals. This potential side effect should be discussed with clients considering estrogen therapy.

Choice C reason: This statement is correct because taking estrogen as prescribed can help decrease muscle mass, which is one of the desired effects of feminizing hormone therapy for transgender women.

Choice D reason: This statement is correct because estrogen therapy can cause infertility. Transgender women undergoing estrogen therapy should be informed about this potential outcome and consider fertility preservation options if they wish to have biological children in the future.

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The nurse is caring for a client on the medical unit when the waste basket catches fire. What is the priority action for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?

Correct Answer is A

Explanation

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