A nurse enters a client's room and sees smoke coming from the client's trash can. Which of the following actions should the nurse take first?

Activate the fire alarm system.

Confine the fire by closing doors and windows.

Rescue the client from immediate danger.

Extinguish the fire if possible.

Answer and Explanation

The Correct Answer is C

A. Activate the fire alarm system: This is important but comes after rescuing anyone in immediate danger.
B. Confine the fire by closing doors and windows: This helps prevent fire spread, but rescue comes first.
C. Rescue the client from immediate danger: According to the RACE acronym for fire response-Rescue, Alarm, Confine, Extinguish-the first step is always to rescue those in immediate danger.
D. Extinguish the fire if possible: Only attempt this if it is safe and others are not in danger.

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Correct Answer is D

Explanation

A. Place the client in a modified Trendelenburg position: This may help with shock after bleeding is controlled, but is not the first action.
B. Apply a tourniquet just above the wound: Tourniquets are a last resort when direct pressure fails to control bleeding.
C. Elevate the extremity: Elevation can help reduce bleeding, but only after direct pressure is applied.
D. Apply pressure directly to the wound: This is the first-line intervention to control bleeding in most cases.

A. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg. B. Orthostatic hypotension increases a client's risk of a pulmonary emboli. C. Orthostatic hypotension increases a client's risk of a fall. D. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg.

Correct Answer is C

Explanation

A. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: It is typically defined by a drop of ≥10 mm Hg diastolic or ≥20 mm Hg systolic.
B. Orthostatic hypotension increases a client's risk of a pulmonary emboli: Orthostatic hypotension does not cause PE; they are unrelated pathophysiologies.
C. Orthostatic hypotension increases a client's risk of a fall: The drop in blood pressure on standing can cause dizziness or fainting, leading to a fall risk.
D. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: The correct threshold is ≥20 mm Hg systolic.

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A nurse enters a client's room and sees smoke coming from the client's trash can. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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