A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Close the window and remove the client’s oxygen.

Sound the fire alarm and activate the emergency response system.

Cover the client with a blanket to smother the flames.

Remove the client from the room and close the door.

Answer and Explanation

The Correct Answer is C

This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.

This will also help contain the fire and prevent it from spreading.

Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.

Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.

Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.

Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.

The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.

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Correct Answer is A

Explanation

This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.

Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.

Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.

Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.

A. Sodium is 144. B. Potassium is 3.0. C. Chloride is 99. D. Calcium is 5.0.

Correct Answer is B

Explanation

Potassium is 3.0.

This is because furosemide is a loop diuretic that can cause hypokalemia (low potassium levels) as a side effect. Hypokalemia can lead to muscle weakness, cramps, cardiac arrhythmias, and digoxin toxicity. The normal range for potassium is 3.5 to 5.0 mEq/L.

Choice A is wrong because sodium is 144 is within the normal range of 135 to 145 mEq/L.

Choice C is wrong because chloride is 99 is within the normal range of 98 to 106 mEq/L.

Choice D is wrong because calcium is 5.0 is within the normal range of 4.5 to 5.5 mg/dL.

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A nurse enters a client’s room and finds the client’s gown is on fire. Which is the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations. What is the priority action?

Correct Answer is A

Explanation

A client is started on furosemide 80 mg every morning. Which lab result needs to be reported to the health care provider?

Correct Answer is B

Explanation

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