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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
It would be inappropriate to delegate the unsupervised task of transferring a client from bed to chair to an unlicensed assistant (UAP) if it was the client's first time out of bed after surgery. In this situation, the client may have specific needs or limitations that require the expertise and assessment of a licensed healthcare provider. The nurse should supervise the transfer to ensure that it is performed safely and appropriately for the client's condition.
Correct Answer is C
Explanation
According to Maslow's hierarchy of needs model, physiological needs such as food, water, and shelter are the most basic and fundamental needs that must be met before higher-level needs can be addressed. In this scenario, the nursing diagnosis of Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients addresses a fundamental physiological need and should be identified as the highest priority for this client. The other nursing diagnoses listed address important needs related to safety, self-care, and psychological well-being, but these needs are considered higher-level needs according to Maslow's hierarchy and should be addressed after the client's basic physiological needs have been met.
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