A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

Close the fire doors and the doors to the clients' rooms.

Activate the fire alarm.

Extinguish the fire.

Remove all clients from the unit.

Answer and Explanation

The Correct Answer is B

Choice A reason: Closing the fire doors and the doors to the clients' rooms is an action that the nurse should take after activating the fire alarm, as it helps to contain the fire and prevent smoke inhalation.

Choice B reason: Activating the fire alarm is the first action that the nurse should take after removing the client from the room, as it alerts the fire department and the rest of the staff and clients about the fire.

Choice C reason: Extinguishing the fire is an action that the nurse should take only if the fire is small and confined, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should use the appropriate fire extinguisher and follow the PASS technique (pull, aim, squeeze, sweep).

Choice D reason: Removing all clients from the unit is an action that the nurse should take only if the fire is large and spreading, and after activating the fire alarm and ensuring the safety of the client and self. The nurse should follow the RACE protocol (rescue, alarm, confine, extinguish/evacuate) and the facility's emergency plan.

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Correct Answer is A

Explanation

Choice A reason: The client's current location and status are important information that the nurse should include in the report, as they affect the continuity and quality of care. The nurse should also inform the oncoming nurse of the reason and results of the chest x-ray, if available.

Choice B reason: The client's partner's visit is not relevant information that the nurse should include in the report, as it does not affect the client's care plan or outcomes. The nurse should focus on the client's clinical data and needs, not their personal or social information.

Choice C reason: The client's routine vital signs are not specific information that the nurse should include in the report, as they do not reflect the client's current condition or changes. The nurse should provide the actual vital signs values and trends, as well as any interventions or responses related to them.

Choice D reason: The client's occupation is not pertinent information that the nurse should include in the report, as it does not influence the client's care plan or outcomes. The nurse should respect the client's privacy and confidentiality and avoid disclosing unnecessary or sensitive information.

A. Administer IV nitroglycerin to a client who is experiencing chest pain. B. Complete a SAD PERSONS assessment scale for a client who has attempted suicide. C. Set up a trauma room for an incoming client who was in a motor-vehicle crash. D. Perform a urinary catheterization for a client who has experienced a cerebrovascular accident.

Correct Answer is D

Explanation

Choice A reason: Administering IV nitroglycerin to a client who is experiencing chest pain is not an appropriate assignment for the float nurse, as it requires advanced cardiac knowledge and skills that the nurse may not have. The charge nurse should assign this task to a nurse who is experienced in the emergency department.

Choice B reason: Completing a SAD PERSONS assessment scale for a client who has attempted suicide is not an appropriate assignment for the float nurse, as it requires mental health expertise and training that the nurse may not have. The charge nurse should assign this task to a nurse who is qualified in psychiatric nursing.

Choice C reason: Setting up a trauma room for an incoming client who was in a motor-vehicle crash is not an appropriate assignment for the float nurse, as it requires emergency preparedness and competence that the nurse may not have. The charge nurse should assign this task to a nurse who is familiar with the trauma protocols and equipment.

Choice D reason: Performing a urinary catheterization for a client who has experienced a cerebrovascular accident is an appropriate assignment for the float nurse, as it is a basic nursing skill that the nurse should have learned and practiced in the medical-surgical unit. The charge nurse should assign this task to the float nurse as long as the nurse is comfortable and confident with the procedure.

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A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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