A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

Close the fire doors on the unit

Use a fire extinguisher to put out the fire

Move any clients in the immediate vicinity.

Activate the fire alarm

Answer and Explanation

The Correct Answer is C

A. Close the fire doors on the unit:
Closing fire doors is a safety measure to contain smoke and flames, but activating the fire alarm is the priority to ensure a swift and comprehensive response.

B. Use a fire extinguisher to put out the fire:
While using a fire extinguisher is an important action, it should come after activating the fire alarm. The fire alarm alerts everyone to the emergency, and then the appropriate personnel can use fire extinguishers as needed.

C. Move any clients in the immediate vicinity:

Priority action during a fire: The priority in any fire situation is to ensure the safety of individuals in the immediate area. The acronym RACE is commonly used in healthcare settings to outline the steps to take in the event of a fire:

Rescue anyone in immediate danger.
Alarm: Activate the fire alarm.
Contain the fire by closing doors.
Extinguish the fire if it is small and safe to do so, or Evacuate the area if necessary.

D. Activate the fire alarm
This is also important but comes after rescuing or moving clients in immediate danger.

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Correct Answer is C

Explanation

A. Glucagon:
Glucagon is not used as an antidote for heparin overdose. It is typically used to treat severe hypoglycemia.

B. Vitamin K:
Vitamin K is the antidote for warfarin, another anticoagulant, but it is not effective for reversing the effects of heparin.

C. Protamine
Protamine is the specific antidote for heparin. It acts by binding to heparin, neutralizing its anticoagulant effects. It is important to note that the administration of protamine should be done carefully, and the dosage must be based on the amount of heparin the patient has received.

D. Calcium:
Calcium is not an antidote for heparin. It is more relevant in cases of calcium channel blocker toxicity or hypocalcemia.

A. “I understand your fears, I was a smoker also.” B. “Don’t worry. The important thing is you have now quit smoking.” C. “Your doctor is a great surgeon. You will be fine.” D. “It’s okay to feel scared. Let’s talk about what you are afraid of.”

Correct Answer is D

Explanation

A. “I understand your fears, I was a smoker also.”
While sharing personal experiences can sometimes be relatable, it may not be the most therapeutic response in this situation. The focus should be on the client's feelings and concerns rather than the nurse's personal history.

B. “Don’t worry. The important thing is you have now quit smoking.”
Dismissing the client's fear with a "don't worry" statement may invalidate the client's emotions. It's important to acknowledge and address the client's feelings rather than downplaying them.

C. “Your doctor is a great surgeon. You will be fine.”
While it's positive to express confidence in the medical team, this response does not directly address the client's emotional concerns. The client's fear may extend beyond the surgical aspect, and it's essential to explore and discuss those fears.

D. “It’s okay to feel scared. Let’s talk about what you are afraid of.”
This response is the most therapeutic as it acknowledges the client's emotions, validates the fear, and opens the door for further communication. It invites the client to express her concerns and allows the nurse to provide support and information based on the client's specific fears.

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A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?

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Naxlex Comprehensive Predictor Exams

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