A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
Close the door to the client's room.
Obtain a fire extinguisher.
Pull the fire alarm panel.
Remove the client from the room.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice B rationale: Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice C rationale: Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice D rationale: The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: A clear liquid diet 1 to 3 days before a colonoscopy minimizes residue in the colon, enhancing mucosal visualization and reducing the risk of missed lesions. Clear liquids include water, broth, tea, and gelatin, which are easily absorbed and leave minimal waste. This dietary preparation complements bowel cleansing agents like polyethylene glycol. Inadequate preparation can obscure polyps or inflammation. Normal stool consistency should be absent during the procedure to ensure optimal diagnostic accuracy.
Choice B rationale: Polypectomy is typically performed during the colonoscopy itself if polyps are detected. Most polyps are removed using snares or biopsy forceps during the same session, reducing the need for a second procedure. Scheduling another procedure is reserved for complex or large lesions requiring advanced techniques. Delaying removal increases the risk of progression to malignancy. Normal colonoscopy findings include pink mucosa and absence of polyps; any deviation warrants immediate intervention when feasible.
Choice C rationale: Restricting intake to only water for 12 hours before the procedure is insufficient and potentially misleading. Colonoscopy preparation requires both dietary modification and pharmacologic bowel cleansing, not just fasting. Water alone does not clear the colon of fecal matter. Additionally, fasting without electrolyte replacement may lead to dehydration and electrolyte imbalance. Normal serum potassium ranges from 3.5 to 5.0 mEq/L; inadequate preparation may cause hypokalemia, especially with laxative use.
Choice D rationale: Enemas are not routinely recommended 2 days before colonoscopy. They may be used adjunctively on the day of the procedure for distal colon cleansing but are insufficient for full bowel preparation. Oral bowel prep agents like polyethylene glycol are preferred for complete evacuation. Enemas only reach the rectosigmoid region and do not cleanse the ascending or transverse colon. Incomplete prep compromises mucosal visualization and diagnostic yield, increasing false-negative rates.
Correct Answer is A
Explanation
Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.
Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.
Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.
Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.
The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.
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