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 A
Explanation
Choice A reason: The client's current location and status are important information that the nurse should include in the report, as they affect the continuity and quality of care. The nurse should also inform the oncoming nurse of the reason and results of the chest x-ray, if available.
Choice B reason: The client's partner's visit is not relevant information that the nurse should include in the report, as it does not affect the client's care plan or outcomes. The nurse should focus on the client's clinical data and needs, not their personal or social information.
Choice C reason: The client's routine vital signs are not specific information that the nurse should include in the report, as they do not reflect the client's current condition or changes. The nurse should provide the actual vital signs values and trends, as well as any interventions or responses related to them.
Choice D reason: The client's occupation is not pertinent information that the nurse should include in the report, as it does not influence the client's care plan or outcomes. The nurse should respect the client's privacy and confidentiality and avoid disclosing unnecessary or sensitive information.
Correct Answer is B
Explanation
Choice A reason: Contacting the client's next of kin to obtain consent for treatment is not a correct action, as it may delay the necessary and urgent care for the client. The nurse should assume that the client would consent to life-saving treatment and act in the client's best interest.
Choice B reason: Proceeding with treatment without obtaining written consent is the correct action, as it is justified by the emergency doctrine. The nurse should provide immediate and appropriate care for the client who is unable to give consent due to their condition.
Choice C reason: Having the client sign a consent for treatment is not a correct action, as the client is disoriented and cannot give informed consent. The nurse should not ask the client to sign any documents that they may not understand or remember.
Choice D reason: Notifying risk management before initiating treatment is not a correct action, as it is not a priority in an emergency situation. The nurse should focus on the client's needs and safety and document the care provided and the rationale for the actions taken.
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