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 A

Explanation

A) "The patient has the virus but the infection is well controlled and not currently transmissible."
An undetectable viral load means that the amount of HIV in the blood is so low that it cannot be detected by standard laboratory tests, typically due to effective antiretroviral therapy. However, the patient still has the HIV virus in their body, and it is essential to continue treatment. An undetectable viral load reduces the risk of transmission, particularly to partners, but it does not eliminate the virus entirely. Hence, the infection is well controlled, but ongoing medication is still necessary to maintain viral suppression.

B) "The syndrome has gone from Stage 3 back to stage 2."
An undetectable viral load does not change the HIV stage. HIV is classified into three stages, with Stage 3 representing AIDS. While effective antiretroviral therapy can prevent the progression to AIDS and help control the viral load, it does not "reverse" the stage of HIV infection. Once a person progresses to Stage 3 (AIDS), they remain in this category even if their viral load becomes undetectable.

C) "The patient can discontinue with antiretroviral therapy until the viral load rises again."
An undetectable viral load indicates successful treatment, but it is crucial for the patient to continue taking antiretroviral medications to maintain viral suppression. Discontinuing therapy increases the risk of viral rebound and drug resistance. Long-term adherence to antiretroviral therapy is essential for keeping the virus under control.

D) "The patient will be prescribed lower doses of antiretroviral medications for 2 months.". The goal of antiretroviral therapy is to maintain viral suppression indefinitely, not to reduce the dose or discontinue it temporarily. Lowering the dose of antiretroviral medications could result in viral rebound and loss of viral suppression. Therefore, consistent, full-dose therapy is required for optimal HIV management.

A. Complete blood count (CBC) B. Electroencephalogram (EEG) C. Computed tomography (CT) scan D. Chest radiograph (chest x-ray)

Correct Answer is C

Explanation

A) "Complete blood count (CBC)":
. A CBC can provide important information about the patient's overall health, including potential signs of infection, anemia, or other underlying conditions. However, in the context of acute neurological symptoms such as left-sided weakness, CT scan is the priority test because it will help quickly determine if there is an acute neurological event, such as a stroke or hemorrhage. While a CBC might be useful later to assess for underlying
conditions or potential causes, it is not the first test to perform in this scenario.

B) "Electroencephalogram (EEG)":
. An EEG is primarily used to diagnose and assess seizure activity or epileptic disorders. While seizures can cause neurological deficits, the patient's sudden onset of left-sided weakness is more suggestive of a stroke, not a seizure. The priority is to rule out stroke with a CT scan, not to assess for seizures with an EEG.

C) "Computed tomography (CT) scan":
. A CT scan is the first diagnostic test to perform in patients with acute neurological deficits such as sudden-onset weakness, especially when a stroke is suspected. A CT scan can quickly detect if the cause is an ischemic stroke (lack of blood flow due to a clot) or a hemorrhagic stroke (bleeding in the brain). Time is critical in the management of stroke, as early intervention with treatments like tPA (tissue plasminogen activator) for ischemic stroke can greatly improve outcomes. The CT scan can help determine if the patient is a candidate for thrombolysis or if other interventions are needed.

D) "Chest radiograph (chest x-ray)":
. While a chest x-ray can be useful for diagnosing respiratory issues, such as pneumonia or congestion, it is not helpful in evaluating the cause of acute neurological symptoms like left-sided weakness. The priority test is a CT scan to evaluate the brain and rule out conditions like stroke or hemorrhage, not a chest x-ray.

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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 A

Explanation

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Correct Answer is C

Explanation

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