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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because this action is not the nurse's responsibility. Coordinating the team and the plan of care is the role of the case manager or the social worker, who can facilitate communication and collaboration among the different disciplines involved in the client's care.
Choice B reason: This is not the correct choice because this action is not the nurse's responsibility. Ordering durable medical equipment for the client's home is the role of the occupational therapist or the physical therapist, who can assess the client's functional needs and abilities and recommend the appropriate devices.
Choice C reason: This is not the correct choice because this action is not the nurse's responsibility. Helping the client obtain financial assistance is the role of the social worker or the financial counselor, who can identify the client's eligibility and options for funding and insurance coverage.
Choice D reason: This is the correct choice because this action is the nurse's responsibility. Performing a dietary assessment is part of the nursing process and the scope of practice of the nurse, who can evaluate the client's nutritional status and needs and provide education and counseling on diet modifications and interventions.
Correct Answer is B
Explanation
Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.
Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.
Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.
Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.
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