A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room.
Which of the following actions should the nurse take first?
Activate the fire alarm system.
Obtain and use a fire extinguisher.
Evacuate clients from the area.
Close the doors and windows on the unit.
The Correct Answer is C
Choice A rationale:
Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.
Choice B rationale:
Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.
Choice C rationale:
Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.
Choice D rationale:
Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Measuring the amount of time the child can hear the sound is not the correct action when performing Weber's test. Weber's test is used to assess hearing acuity and lateralization. In this test, a vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked if the sound is heard equally in both ears or if it is louder in one ear. This helps identify whether there is a conductive or sensorineural hearing loss. The duration of hearing the sound is not relevant to this test.
Choice B rationale:
Obtaining a tympanogram reading is not necessary before initiating Weber's test. Tympanometry assesses the movement of the eardrum in response to changes in air pressure and can help diagnose conditions like middle ear effusion or eustachian tube dysfunction. However, Weber's test focuses on lateralization of sound and does not require tympanogram readings.
Choice C rationale:
Placing a vibrating tuning fork on the top of the child's head is the correct action for performing Weber's test. By doing so, the nurse can assess whether the sound is perceived equally in both ears or if it is lateralized to one ear. If the sound is lateralized, it can provide valuable information about the type of hearing loss the child may have, whether it's conductive or sensorineural.
Choice D rationale:
Holding a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears is not the correct technique for Weber's test. Placing the tuning fork directly on the patient's forehead is essential for accurate assessment. Holding it close to the ears can lead to misinterpretation of the test results.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should include the statement, "Use a product with DEET on your skin and clothes when you are walking in a wooded area," in the educational program on Lyme disease. DEET is a widely used insect repellent effective against ticks. It is recommended to prevent tick bites in wooded and grassy areas. The rationale behind this choice is to educate the public about practical measures to reduce the risk of Lyme disease. DEET repels ticks, reducing the chances of tick attachment and, consequently, the transmission of Lyme disease.
Choice B rationale:
The statement, "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick," is incorrect. The incubation period for Lyme disease can vary from 3 to 30 days after the tick bite. Symptoms usually appear within 3 to 14 days but can take longer to manifest. Providing inaccurate information can lead to misunderstanding and inadequate preventive measures.
Choice C rationale:
The statement, "Remove embedded ticks by squeezing the body with tweezers," is incorrect. Improper removal of ticks, such as squeezing the body, can lead to the injection of tick fluids into the host, increasing the risk of disease transmission. The correct method for tick removal is to use fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pull upward with steady, even pressure. This helps ensure the tick is removed entirely and reduces the risk of infection.
Choice D rationale:
The statement, "If bitten by a tick, testing for Lyme disease should occur within 2 weeks," is incorrect. Testing for Lyme disease immediately after a tick bite is not recommended because it takes time for the body to produce antibodies detectable by the tests. Testing too early can yield false-negative results. Healthcare providers may recommend testing if symptoms develop, but waiting for a few weeks after the bite increases the accuracy of the test results.
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