Which action should the nurse take first when discovering a fire in the client's bathroom trash can?

Leave the com to pull the fire alarm

Remove the client from their room and relocate there to a safe space

Douse the client with a fire extinguisher, using a back-and-forth motion

Close all the doors to the client's room

Answer and Explanation

The Correct Answer is B

A) Leave the room to pull the fire alarm: While pulling the fire alarm is an important step in alerting others to the fire, it is not the nurse's priority action when a fire is discovered in the client's bathroom. The immediate concern is the safety of the client. The nurse should prioritize getting the client out of harm’s way before any other actions.

B) Remove the client from their room and relocate to a safe space: This is the most appropriate first action. The nurse’s first responsibility is to ensure the client's safety. Removing the client from the immediate danger zone, which is the room with the fire, is the priority. This action helps prevent injury or death from smoke inhalation or burns. Once the client is safe, the nurse can then proceed to alert others and address the fire as needed.

C) Douse the client with a fire extinguisher, using a back-and-forth motion: This action is inappropriate because the client should never be doused with a fire extinguisher. The fire extinguisher is intended for controlling the fire, not for use on individuals. Additionally, extinguishing a fire should not take priority over ensuring the client's immediate safety by removing them from the room.

D) Close all the doors to the client's room: Closing doors can help contain the fire and prevent it from spreading, but it is not the first priority. The immediate action should focus on removing the client from the room to a safe space. After ensuring the client's safety, the nurse can then close the doors to help contain the fire while awaiting assistance.Top of FormBottom of Form

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Correct Answer is B

Explanation

A. Pernicious anemia:
Pernicious anemia is primarily caused by a deficiency in vitamin B12, often due to a lack of intrinsic factor needed for absorption in the gut. It typically presents with symptoms like weakness, fatigue, and neurological manifestations such as numbness or tingling. However, the client’s presentation does not suggest a vitamin B12 deficiency or neurological signs. Additionally, pernicious anemia is not typically associated with heavy menstrual periods,
which are more indicative of blood loss anemia.

B. Blood loss anemia:
Blood loss anemia is the most likely diagnosis in this case, especially in the context of heavy menstrual periods, which can cause significant blood loss over time. The client’s hemoglobin level of 6.9 g/dL indicates severe anemia, which is consistent with the cumulative effects of chronic blood loss. This type of anemia results from a decrease in red blood cell count due to bleeding, which can lead to symptoms like weakness, fatigue, and pallor.

C. Sickle cell anemia:
Sickle cell anemia is a genetic condition characterized by abnormally shaped red blood cells, which can lead to hemolysis and episodes of pain. While it can cause symptoms like fatigue and weakness, sickle cell anemia typically presents earlier in life and is more associated with episodes of severe pain and organ damage. Additionally, the patient’s history does not mention episodes of pain or other hallmark signs of sickle cell disease, such as swelling in the hands or feet or recurrent infections.

D. Aplastic anemia:
Aplastic anemia occurs when the bone marrow fails to produce enough blood cells, including red blood cells, white blood cells, and platelets. It presents with symptoms like weakness, fatigue, frequent infections, and bruising. Although this client does have anemia, the lack of additional signs (such as petechiae, infections, or bleeding) makes this diagnosis less likely. Aplastic anemia is also usually diagnosed with bone marrow biopsy, which is not suggested by this client's presentation.

A. Rapid loss of consciousness B. Excessive urination C. Lack of appetite D. Excessive thirst E. Slow shallow respirations.

Correct Answer is ["B","D"]

Explanation

A. Rapid loss of consciousness:
Rapid loss of consciousness is not typically a sign of hyperglycemia in type 1 diabetes. While hyperglycemia can lead to diabetic ketoacidosis (DKA) if it is severe and prolonged, which can cause confusion or stupor, rapid loss of consciousness is more often associated with severe hypoglycemia (low blood sugar), not hyperglycemia. Therefore, this is not a typical symptom of hyperglycemia in type 1 diabetes.

B. Excessive urination:
This is a correct sign of hyperglycemia. When blood sugar levels rise, the kidneys try to filter out the excess glucose, which leads to increased urination (polyuria). The kidneys cannot reabsorb all the glucose, and the excess glucose in the urine draws water with it, leading to more frequent urination.

C. Lack of appetite:
A lack of appetite is not typically associated with hyperglycemia. In fact, people with hyperglycemia or high blood sugar are often more likely to experience increased hunger (polyphagia) due to insulin resistance or the body’s inability to utilize glucose properly. A lack of appetite is more common in hypoglycemia (low blood sugar) or in conditions like diabetic ketoacidosis (DKA), where nausea and vomiting are also common. Therefore, this is not a sign of hyperglycemia.

D. Excessive thirst:
This is a correct sign of hyperglycemia. High blood sugar leads to excessive urination, which in turn causes dehydration. As a result, individuals with hyperglycemia may experience polydipsia (excessive thirst) as the body tries to compensate for the fluid loss.

E. Slow shallow respirations:
Slow, shallow respirations are typically a sign of respiratory depression and are more likely to be associated with hypoventilation or complications like diabetic ketoacidosis (DKA), rather than hyperglycemia alone. In DKA, a common complication of poorly controlled type 1 diabetes, respirations may become deep and rapid (Kussmaul respirations) in an attempt to blow off excess CO2 and correct the acidosis. Therefore, slow, shallow respirations are not a typical sign of hyperglycemia.

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Which action should the nurse take first when discovering a fire in the client's bathroom trash can?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 6.9 g/dL. The nurse suspects which of the following types of anemia?

Correct Answer is B

Explanation

The nurse recognizes which of the following as signs and symptoms of hyperglycemia type I diabetes mellitus? Select all that apply,

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

You enter the room of your known diabetic patient and find them unresponsive. After ensuring they are breathing and have a patent airway, you check a blood glucose and find it to be 30 mg/dL. Which of the following medications should be the priority to administer?

The nurse is preparing to administer a shot of vitamin B12 to a client with low hemoglobin. The nurse knows that this medication is most indicative of which type of anemia?

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