A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
Use a fire extinguisher at the source of the smoke.
Close the doors to the room and to the bathroom.
Activate the fire alarm system.
Assist the client to a nearby common area.
The Correct Answer is D
Choice A Reason:
Using a fire extinguisher at the source of the smoke is not appropriate. While using a fire extinguisher could potentially help contain a small fire, it's crucial to prioritize rescuing those in immediate danger and alerting others about the fire first by activating the fire alarm. This action ensures that help is on the way and that everyone is aware of the emergency.
Choice B Reason:
Closing the doors to the room and to the bathroom is not appropriate. Closing doors can help contain smoke and fire to some extent, but again, the priority in an emergency situation like this is to rescue those in immediate danger then activate the fire alarm to ensure a swift response and alert others.
Choice C Reason:
Activate the fire alarm system is appropriate. Activating the fire alarm alerts others in the facility and initiates the emergency response protocol, helping to ensure that help is on the way while potentially preventing the spread of fire. However, this step should be taken after assisting the client to safety as they are in immediate danger.
Choice D Reason:
Assisting the client who is in immediate danger to a nearby common area should be the furst step that the nurse takes before alerting other people of the fire. (RACE protocol)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Ensure the blinds in the client's room remain open is not appropriate. Bright light can contribute to sensory overload. It's better to create a subdued and calming environment, so keeping the blinds closed or partially closed might help reduce excess stimuli.
Choice B Reason:
Place the client in a room near the nurses' station is not appropriate. Being near the nurses' station could increase the noise and activity around the client, potentially worsening sensory overload. It's advisable to place the client in a quieter area away from high-traffic zones to minimize auditory and visual stimulation.
Choice C Reason:
Play quiet music in the client's room is incorrect. While soothing music might help some individuals relax, for someone experiencing sensory overload, even low-volume music could add to the stimuli. Silence or minimal ambient noise might be more beneficial.
Choice D Reason:
Break up nursing care into small, frequent sessions is correct. This action is beneficial for managing sensory overload. Breaking up care into smaller sessions allows for adequate rest periods between activities, reducing the overall sensory input at any given time.
Correct Answer is B
Explanation
Choice A Reason:
Refill the prescription every 12 months. This statement focuses on the frequency of prescription refills rather than guidance on the medication's use. While it's important to keep prescriptions up to date, this instruction doesn't directly relate to the administration or use of sublingual nitroglycerin for angina.
Choice B Reason:
Take a second tablet after 5 minutes for unrelieved chest pain. This advice is crucial because if the chest pain persists after the first tablet, taking a second tablet after 5 minutes (and seeking emergency medical assistance if pain persists after the second tablet) is part of the recommended protocol for managing unstable angina with sublingual nitroglycerin.
Choice C Reason:
Swallow the tablet whole with a glass of water. Sublingual nitroglycerin is designed to dissolve under the tongue, not to be swallowed. The medicine is absorbed through the blood vessels in the mouth to provide rapid relief for angina symptoms. Instructing the patient to swallow the tablet defeats the purpose of sublingual administration.
Choice D Reason:
Store the medication in the refrigerator. Nitroglycerin should generally be stored in a cool, dry place and away from direct sunlight, but refrigeration is not necessary. Storing it in the refrigerator might actually alter the medication's effectiveness or consistency, making it less reliable for quick absorption when needed during an angina episode.
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