A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?

Use an extinguisher to put out the fire.

Pull the fire alarm.

Close the doors to client rooms.

Turn oﬀ any electrical equipment in the room.

Answer and Explanation

The Correct Answer is B

After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.

Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning oﬀ electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.

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Correct Answer is A, C, B, D

Explanation

First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.

A. Notify the primary care provider. B. Assess the client's vital signs. C. Calculate the infused volume. D. Complete an incident report.

Correct Answer is B

Explanation

If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse eﬀects from the rapid infusion of ﬂuids.

Option a is incorrect because notifying the primary care provider is important but not the first intervention.

Option c is incorrect because calculating the infused volume is important but not the first intervention.

Option d is incorrect because completing an incident report is important but not the first intervention.

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A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A, C, B, D

Explanation

A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea. (Arrange the steps, placing them in the order of performance. Use all the steps.)

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse is teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?

A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?

A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?