A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse
implement?
Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
The Correct Answer is B
Choice A Reason: Instructing UAPs to transfer all non-ambulatory clients via wheelchairs is not a good intervention, as it may expose the clients and the UAPs to smoke and fire, and cause panic and congestion in the hallways. The charge nurse should follow the RACE protocol (Rescue, Alarm, Contain, Extinguish), which means rescuing only those clients who are in immediate danger, and containing the fire by closing doors and windows.
Choice B Reason: Following the RACE acronym, evacuation of those in immediate danger is the priority. Instructing ambulatory clients to move toward the nearest fire exit is the most efficient way to clear the unit. Nursing staff must guide these individuals to safety first to minimize congestion and allow for focused assistance.
department's efforts. The charge nurse should follow the RACE protocol, which means evacuating only as a last resort, and only after receiving instructions from the fire department.
Choice C Reason: Staying in rooms is a "defend in place" strategy, but it is inappropriate once an official evacuation order has been issued by the operator. Closing doors is vital to contain smoke and fire, but instructing everyone to remain stationary during an active evacuation order increases the risk of injury.
Choice D Reason: Announcing in a calm voice that all visitors should proceed immediately to the first floor via the service elevators is not a good intervention, as it may endanger the visitors and cause more damage. The charge nurse should follow the RACE protocol, which means alarming others by activating the fire alarm system and calling 911. The charge nurse should also instruct visitors not to use elevators during a fire, as they may malfunction or trap them inside.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This intervention is not appropriate because it violates the client's privacy and confidentiality. The health department does not need to be notified of the client's condition, as breast cancer is not a communicable disease or a public health threat. The nurse should respect the client's wishes and only share information with authorized persons or agencies.
B) This intervention is appropriate because it respects the client's autonomy and encourages informed decision-making. The nurse should advise the client to consider the benefits and risks of disclosing or withholding the diagnosis from the family, and how it may affect their relationships and support systems. The nurse should also provide relevant information and resources to help the client make an informed choice.
C) This intervention is not appropriate because it contradicts the client's decision and may cause confusion or distress for the family. The nurse should not suggest genetic screening to the family without the client's consent, as this may imply that they are at risk of developing breast cancer or other genetic disorders. The nurse should also avoid giving unsolicited advice or opinions that may interfere with the client's autonomy.
D) This intervention is not appropriate because it imposes the nurse's values and beliefs on the client. The nurse should not explain that the family has a right to know of potential health problems, as this may imply that the client is wrong or selfish for withholding the diagnosis. The nurse should acknowledge and respect the client's perspective and preferences, and support them in coping with their condition.
Correct Answer is A
Explanation
Choice A Reason: This is the best action because it prevents the spread of infection to other clients and staff. Mumps is a viral infection that causes inflammation of the salivary glands and can be transmitted by respiratory droplets. The nurse should place an isolation cart outside of the room and wear a mask, gloves, and gown when entering.
Choice B Reason: This is not the first priority because it does not address the risk of infection. The nurse should schedule bedside play time with the occupational therapist to promote the child's development and coping, but this can be done later.
Choice C Reason: This is not the first priority because it does not ensure that infection control measures are in place. The nurse should instruct the child's parents about the need for transmission precautions and educate them on how to care for their child at home, but this can be done later.
Choice D Reason: This is not the first priority because it does not prevent the spread of infection. The nurse should assign the child to a room close to the nurse's station to monitor his condition and provide comfort, but this is not a critical intervention.
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