The nurse is extinguishing a fire that has broken out in the workplace.
Which is the first step the nurse should take?

Squeeze the handles together.

Pull the pin found between the handles.

Aim the nozzle at the base of the flames.

Sweep the nozzle back and forth at the base of the flames.

Answer and Explanation

Correct Answer : A,C

Choice A rationale:

Instructing the clients to use the call light is an important action to prevent falls. If the clients need assistance or have to leave their beds, they should use the call light to alert the nurse or healthcare provider. Prompt response to call lights can prevent clients from attempting to move on their own and potentially falling.

Choice B rationale:

Keeping the clients' rooms dark is not a safe practice, especially for clients at risk for falls. Dim lighting can increase the risk of tripping or falling, especially during nighttime when visibility is already reduced. Adequate lighting in the clients' rooms is essential to ensure their safety.

Choice C rationale:

Moving overbed tables away from the bed is crucial in preventing falls. Overbed tables can obstruct the clients' movement, leading to accidents. By keeping the area around the bed clear, the clients have more space to maneuver safely, reducing the risk of falls.

Choice D rationale:

Performing client checks every 4 hours is a good practice, but it is not sufficient for clients at high risk for falls, especially during the night shift when they may need assistance to use the bathroom or move in bed. Frequent checks and availability to assist clients promptly are essential to prevent falls effectively.

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Correct Answer is B

Explanation

Choice A rationale:

Airborne transmission typically involves smaller particles that can remain suspended in the air for longer periods. Sneezing, in this case, usually produces smaller droplets that can travel farther distances and potentially infect individuals beyond a few feet away.

Choice B rationale:

Direct contact transmission occurs when there is physical contact between an infected person and a susceptible individual. In this scenario, the infected drainage from the client's wound directly touches the nurse's cut, leading to infection. This type of transmission is characterized by the transfer of microorganisms through physical touch or contact with the skin.

Choice C rationale:

Droplet contact transmission involves larger respiratory droplets that are expelled when a person coughs, sneezes, or talks. These droplets typically do not travel far and can only infect people who are in close proximity. In this case, the scenario describes a client coughing on their hand and another person becoming infected by touching the contaminated door handle. This aligns with direct contact transmission rather than droplet contact transmission.

Choice D rationale:

Indirect contact transmission refers to the transfer of an infectious agent from a contaminated surface or object to a susceptible person. However, the scenario provided does not involve the nurse coming into contact with a contaminated surface but rather with the infected drainage directly. Therefore, this scenario is best categorized under direct contact transmission.

A. The client is expelling too much carbon dioxide. B. The client's blood oxygen level indicates hypoxemia. C. The client has developed an inflammation of the phrenic nerve. D. The client is using his intercostal muscles to breathe.

Correct Answer is C

Explanation

Choice A rationale:

Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.

Choice B rationale:

Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.

Choice C rationale:

Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.

Choice D rationale:

Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.

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The nurse is extinguishing a fire that has broken out in the workplace.Which is the first step the nurse should take?

Nursing Test Bank

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The nurse is extinguishing a fire that has broken out in the workplace.
Which is the first step the nurse should take?