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. 2-6 hours before meals:
This timeframe is too long for rapid-acting insulin like Lispro. Rapid-acting insulins, such as Lispro, begin to work quickly after administration, typically within 15 minutes, and peak around 1 to 2 hours after injection. Administering it 2-6 hours before meals would not align with the timing of food intake and would likely lead to hypoglycemia before the meal. Timing of rapid-acting insulin should be closer to the meal to match the rise in blood glucose levels that occurs after eating.

B. Lispro lasts 24 hours and does not have to be timed with meals:
This statement is incorrect. Lispro is a rapid-acting insulin, and its duration of action is much shorter than 24 hours, typically lasting about 3-5 hours. It is crucial to time the administration of Lispro with meals to match its peak action with the rise in blood glucose levels after eating. A long-acting insulin would be the type that lasts for 24 hours, but that is not the case with Lispro.

C. 15-30 minutes before meals:
Lispro is a rapid-acting insulin, and its onset of action occurs within 15 minutes after injection. It is most effective when administered within 15-30 minutes before the start of a meal, as it peaks in about 1-2 hours and works to regulate blood glucose levels during and after the meal. This timing ensures that insulin works in concert with the rise in blood glucose following food intake, helping prevent hyperglycemia.

D. 60 minutes before meals:
Administering Lispro 60 minutes before a meal is too early. Rapid-acting insulins, such as Lispro, begin working quickly and reach peak action within 1-2 hours. If administered too far in advance, there is a risk that the insulin may have peaked before the meal, leading to a potential drop in blood glucose levels before the meal is consumed. This could result in hypoglycemia. Therefore, administering it closer to the meal, within 15-30 minutes, is the optimal timing.

A. Obtain samples for urine culture and urinalysis. B. Insert a Foley catheter. C. Begin broad-spectrum IV antibiotics. D. Prepare the client for a CT scan

Correct Answer is A

Explanation

A) Obtain samples for urine culture and urinalysis:
This is the first priority. The symptoms described—urinary frequency, dysuria (painful urination), and fever—are suggestive of a urinary tract infection (UTI). To confirm the diagnosis and identify the causative organism, it is critical to obtain a urine sample for both a urinalysis and urine culture. The culture will help guide antibiotic therapy once the organism is identified. This is the foundational step before initiating any treatment. The results will also help determine whether the infection is localized or more severe, like a pyelonephritis
or systemic infection.

B) Insert a Foley catheter:
Inserting a Foley catheter may be necessary if the patient is unable to void, but it is not the first intervention in this case. A Foley catheter is generally used for urinary retention or if monitoring of urine output is necessary. In the context of suspected UTI symptoms, a Foley catheter should only be inserted if there is a clear need, not just for the convenience of obtaining a sample. Additionally, inserting a Foley catheter could introduce bacteria if the patient is not already catheterized and should therefore be avoided unless medically indicated.

C) Begin broad-spectrum IV antibiotics:
While starting antibiotics is important in treating a suspected UTI, especially in the presence of fever and potential infection, obtaining a urine sample for culture and urinalysis should be done first. This allows the healthcare team to tailor antibiotic therapy based on the culture results, reducing the risk of unnecessary or incorrect antibiotic use. If the patient is febrile and appears severely ill, broad-spectrum antibiotics may be started after obtaining the urine sample, but the culture and urinalysis must still be prioritized.

D) Prepare the client for a CT scan:
While imaging studies like a CT scan may be helpful in evaluating for complications, they are not the first step in managing the patient’s symptoms. Obtaining the urine sample and identifying whether an infection is present is essential for guiding further management. A CT scan may be ordered later if the clinical suspicion for complications remains high after the initial evaluation and lab results.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

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