A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first?
A client who is confused and restrained for safety
A client who is 1 day postoperative following thoracic surgery and has a chest tube
A client who is in Buck's traction for a left hip fracture
A client who is receiving IV chemotherapy and is ambulatory
The Correct Answer is A
Choice A reason: This is the correct choice because this client has the highest risk of injury or death in the event of a fire. The client is confused and may not understand the situation or follow instructions. The client is also restrained and cannot move or escape without assistance. The nurse should evacuate this client first and remove the restraints as soon as possible.
Choice B reason: This is not the correct choice because this client has a moderate risk of injury or death in the event of a fire. The client is postoperative and has a chest tube, which may limit their mobility and require special equipment. However, the client is not confused or restrained and can cooperate with the evacuation process. The nurse should evacuate this client after the confused and restrained client.
Choice C reason: This is not the correct choice because this client has a low risk of injury or death in the event of a fire. The client is in Buck's traction, which is a type of skin traction that does not require pins or wires. The client can be easily moved by releasing the weights and securing the traction to the bed. The nurse should evacuate this client after the postoperative and chest tube client.
Choice D reason: This is not the correct choice because this client has the lowest risk of injury or death in the event of a fire. The client is receiving IV chemotherapy, which is a treatment that can be stopped and resumed later. The client is also ambulatory, which means they can walk and move without assistance. The nurse should evacuate this client last or ask them to evacuate themselves.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because checking on a client whose telemetry monitor is continuously beeping is a task that requires nursing judgment and assessment skills. The nurse should not delegate this task to the AP, but rather perform it themselves or notify the health care provider.
Choice B reason: This is the correct choice because tagging a malfunctioning piece of equipment as broken is a task that does not involve direct client care or clinical decision making. The nurse can delegate this task to the AP, who can follow the facility's policy and procedure for reporting and removing faulty equipment.
Choice C reason: This is not the correct choice because determining whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula is a task that involves administering medication and monitoring the client's oxygenation status. The nurse should not delegate this task to the AP, but rather perform it themselves and document the results.
Choice D reason: This is not the correct choice because instructing a client about the use of an incentive spirometer is a task that involves providing client education and evaluating the client's understanding and compliance. The nurse should not delegate this task to the AP, but rather perform it themselves and document the outcomes.
Correct Answer is B
Explanation
Choice A reason: This is not the correct choice because the Good Samaritan Act is a law that protects health care providers and other individuals from legal liability when they provide emergency care to someone who is injured or ill outside of a health care facility. The act does not apply to the staff in the emergency department, who are expected to follow the standards of care and obtain consent for treatment.
Choice B reason: This is the correct choice because implied consent is a type of consent that is assumed when a client is unable to give verbal or written consent due to their condition, and the treatment is necessary to save their life or prevent further harm. The staff can proceed with emergency surgery based on implied consent, as the client is unconscious and has extensive internal injuries that require immediate intervention.
Choice C reason: This is not the correct choice because a living will is a document that expresses a client's wishes regarding their end-of-life care, such as whether they want to receive life-sustaining treatments or not. A living will does not apply to the client in this scenario, who is not terminally ill or in a persistent vegetative state, and who may recover from their injuries with surgery.
Choice D reason: This is not the correct choice because nonmaleficence is an ethical principle that means to do no harm or prevent harm to the client. Nonmaleficence does not permit the staff to proceed with emergency surgery, as it does not override the need for consent. The staff should also consider the principle of beneficence, which means to do good or promote the well-being of the client.
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