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: A hematocrit level of 33.4% is slightly below the normal range, which may indicate mild anemia. While this is important to monitor, it is not as urgent as a high white blood cell count, which could indicate an infection. Mild anemia can typically be managed perioperatively without significant risk.

Choice B reason: A white blood cell count of 15.5 x10/uL is significantly elevated and suggests an active infection or inflammatory process. Before proceeding with surgery, it is crucial to identify and treat any infections to prevent postoperative complications, such as sepsis. This value is the most critical to report to the healthcare provider to ensure the safety of the surgical procedure.

Choice C reason: A platelet count of 386,000 mm³ is within the normal range and does not indicate any immediate risk of bleeding or clotting disorders. Thus, this value does not necessitate urgent reporting before surgery.

Choice D reason: A hemoglobin level of 12.2 g/dL is at the lower end of the normal range, indicating borderline anemia. Although it is important to consider, it does not present as immediate a concern as a potential infection. The surgery can generally proceed with closer monitoring of the client's hemoglobin levels.

A. Conduct a client care conference B. Provide information about advance directives C. Orient the client to his room D. Develop a plan of care

Correct Answer is C

Explanation

Choice A reason: Conducting a client care conference is important for multidisciplinary care planning, but it may not immediately address the client's safety needs upon admission. Safety measures should be implemented promptly to prevent potential accidents or confusion.

Choice B reason: Providing information about advance directives is crucial for ensuring that the client's wishes are respected during their care. However, this does not directly address immediate safety concerns that may arise from being in a new environment.

Choice C reason: Orienting the client to his room is essential to promote client safety. This includes familiarizing the client with the layout of the room, location of the bathroom, call bell, and any other essential features. It helps prevent falls and accidents by reducing confusion and ensuring the client knows how to access help if needed.

Choice D reason: Developing a plan of care is critical for long-term management of the client's health needs. However, immediate safety concerns should be addressed first to ensure a safe environment for the client from the outset.

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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?

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