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 C

Explanation

Choice A reason: A 32-year-old male with a femur fracture in traction is stable but needs ongoing pain management and monitoring for complications like infection or deep vein thrombosis (DVT). While this client requires attention, they are not in immediate critical condition compared to other patients on the list.

Choice B reason: A 38-year-old female with a grade 1 liver laceration admitted 2 days ago also requires close observation for signs of bleeding or worsening liver function. However, given that the liver laceration is of a lesser severity (grade 1), the immediate priority is less critical compared to a client with respiratory compromise.

Choice C reason: A 41-year-old male with 4 rib fractures, pneumothorax, and a chest tube is the highest priority. The presence of pneumothorax indicates a potential life-threatening condition that requires close monitoring to ensure the chest tube is functioning correctly and the lung is re-expanding. Any compromise in the chest tube's functionality can lead to respiratory distress or failure, making this client the most critical and requiring immediate assessment.

Choice D reason: A 55-year-old female admitted 6 days ago with a chest contusion and scheduled for discharge today is likely stable and does not have the same level of urgency as a client with a pneumothorax. This client needs final evaluations and discharge planning, but their condition does not present an immediate life-threatening risk.

A. A postoperative client preparing for discharge with a new medication. B. A client requiring daily dressing changes of a recent surgical incision. C. A client scheduled for a chest x-ray after insertion of a nasogastric tube. D. A client with asthma who requested a nebulizer treatment during the previous shift.

Correct Answer is D

Explanation

Choice A reason: While it is important to prepare the postoperative client for discharge and ensure they understand how to take their new medication, this situation is less urgent than addressing a potential respiratory issue.

Choice B reason: Changing the dressing on a recent surgical incision is part of routine care and can be scheduled after more urgent needs are addressed. The client’s wound care is important, but it does not take precedence over potential respiratory distress.

Choice C reason: Although the chest x-ray is necessary to confirm the correct placement of the nasogastric tube, this can be done after the more immediate concern of a respiratory issue is addressed. The nasogastric tube will remain in place for feeding or drainage in the meantime.

Choice D reason: This client should be assessed first because asthma can lead to respiratory distress or an asthma attack, which requires prompt intervention. Since the client requested a nebulizer treatment during the previous shift, it is crucial to assess their current respiratory status and administer the treatment if necessary to prevent any complications.

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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

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Correct Answer is D

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