A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Extinguish the fire if possible.

Rescue the client from immediate danger.

Activate the fire alarm system.

Confine the fire by closing doors and windows.

Answer and Explanation

The Correct Answer is B

The first action the nurse should take in this situation is to rescue the client from immediate danger. This means ensuring that the client is safely removed from the room and away from the fire. The safety of the client is the top priority in this situation. Once the client is safe, the nurse can then take further actions such as activating the fire alarm system and attempting to extinguish the fire if possible.

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Correct Answer is D

Explanation

The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight oﬀ the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.

A. "Oh, for gosh sakes. it doesn't look that bad." B. "I understand, but you are going to have to look someday." C. "Respect your wish not to look at it right now." D. "You won't be able to go home until you look at it."

Correct Answer is C

Explanation

The appropriate response by the nurse in this situation would be to respect the young man's wish not to look at the wound during dressing changes. This response shows empathy and understanding toward the patient's feelings and emotions and allows him to have control over his own care. It is important for healthcare providers to respect their patient's autonomy and decisions regarding their own care.

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A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. What actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

Correct Answer is D

Explanation

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse is caring for a client who is scheduled for an elective surgical procedure. In order to ensure informed consent, the nurse should take which of the following actions?

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

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