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

When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV ﬂuids to use when administering a unit of packed red blood cells.

A. Disturbed Sleep Pattern related to difficulty staying asleep B. Disturbed Thought Processes related to chronic insomnia C. Risk for injury related to somnambulism D. Risk for Impaired Gas Exchange related to sleep apnea

Correct Answer is C

Explanation

The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.

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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

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

Correct Answer is D

Explanation

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Correct Answer is C

Explanation

A client has accepted the fact that they need bypass surgery for a blocked artery and has been admitted to the hospital. Which one of the following stages of illness is this client experiencing?

The nurse has performed an assessment of a client scheduled for discharge to be cared for by the family. Which situation would the nurse question regarding discharge of this client to be cared for by the family?

The nurse is oﬀering free occult blood screenings at a community health fair. Which level of practice is the nurse providing?

When planning interventions to promote a client's appetite, which of the following would be included in the client's plan?

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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?