A charge nurse is reinforcing teaching for a newly licensed nurse about how to apply wrist restraints for a client.
Which of the following actions should the charge nurse identify as an indication that the nurse understands the instructions?
Ties the straps of the restraints in a double knot.
Ties the restraints to the side rails.
Places the padding of the restraints against the client's bony prominences.
Inserts one finger between the client's wrist and the restraint.
The Correct Answer is B
Choice A rationale:
Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.
Choice B rationale:
Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.
Choice C rationale:
Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Airborne transmission typically involves smaller particles that can remain suspended in the air for longer periods. Sneezing, in this case, usually produces smaller droplets that can travel farther distances and potentially infect individuals beyond a few feet away.
Choice B rationale:
Direct contact transmission occurs when there is physical contact between an infected person and a susceptible individual. In this scenario, the infected drainage from the client's wound directly touches the nurse's cut, leading to infection. This type of transmission is characterized by the transfer of microorganisms through physical touch or contact with the skin.
Choice C rationale:
Droplet contact transmission involves larger respiratory droplets that are expelled when a person coughs, sneezes, or talks. These droplets typically do not travel far and can only infect people who are in close proximity. In this case, the scenario describes a client coughing on their hand and another person becoming infected by touching the contaminated door handle. This aligns with direct contact transmission rather than droplet contact transmission.
Choice D rationale:
Indirect contact transmission refers to the transfer of an infectious agent from a contaminated surface or object to a susceptible person. However, the scenario provided does not involve the nurse coming into contact with a contaminated surface but rather with the infected drainage directly. Therefore, this scenario is best categorized under direct contact transmission.
Correct Answer is C
Explanation
The correct answer is choice C: Move any clients to safety.
Choice C rationale: The nurse's priority is always client safety. In the event of an electrical issue that poses a potential risk, such as smoke or fire, the nurse should first ensure that any clients in the area are moved to a safe location. This aligns with the widely-used RACE acronym for fire response (Rescue, Alarm, Confine, Extinguish), which highlights the importance of removing individuals from danger before attending to other aspects of fire safety.
Choice A rationale: Using a fire extinguisher is an appropriate action to take when dealing with a small, manageable fire. However, in this scenario, ensuring client safety takes precedence over attempting to extinguish the source of the smoke. This is also in line with the RACE mnemonic, which emphasizes the importance of prioritizing evacuation.
Choice B rationale: Activating the fire alarm is an important step to alert others in the building about a potential fire and the need for evacuation. However, the priority remains client safety, so moving clients to a safe location should be the nurse's initial response, following the RACE acronym.
In summary, the nurse's priority action when encountering an electrical hazard is to move clients to safety. After ensuring client safety, the nurse can then activate the fire alarm and, if trained to do so, use a fire extinguisher on the outlet if necessary. This approach aligns with the RACE mnemonic, which serves as a guideline for fire response.
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