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 D
Explanation
Choice A reason: This is not the correct choice because requesting orientation to the medical-surgical unit is not the first action the nurse should take. Orientation is a process that takes time and planning, and it may not be feasible or necessary for a temporary assignment. The nurse should first ensure that they are competent to perform the tasks and procedures required on the medical-surgical unit.
Choice B reason: This is not the correct choice because referring to the assigned resource nurse regarding client assignments is not the first action the nurse should take. The resource nurse is a person who can provide guidance and support to the nurse during the shift, but they are not responsible for determining the nurse's competencies or assigning clients. The nurse should first communicate with the charge nurse, who is the leader of the unit and has the authority to assign clients according to the nurse's skills and experience.
Choice C reason: This is not the correct choice because informing the nursing supervisor of the lack of experience on the medical-surgical unit is not the first action the nurse should take. The nursing supervisor is a person who can oversee the staffing and operations of the nursing units, but they are not directly involved in the clinical care of the clients or the education of the staff. The nurse should first consult with the charge nurse, who can assess the nurse's competencies and provide appropriate resources and education.
Choice D reason: This is the correct choice because clarifying competencies with the medical-surgical charge nurse is the first action the nurse should take. The charge nurse is a person who can evaluate the nurse's skills and knowledge, assign clients according to the nurse's level of expertise, and provide orientation and training as needed. The nurse should be honest and proactive in communicating their competencies and learning needs to the charge nurse.
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.
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