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 C

Explanation

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

A. I make sure all throw rugs are removed from the client’s walking path. B. I document my activities with the client before I leave for the day. C. If I have any questions about the plan of care, I will contact you. D. I give the client his medications when the wife is grocery shopping

Correct Answer is D

Explanation

I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.

Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.

Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.

Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.

Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.

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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 nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Correct Answer is C

Explanation

A home health nurse is evaluating a health aide for a client with Alzheimer’s Disease. What statement by the health aide would require the nurse to re-evaluate and correct the plan of care?

Correct Answer is D

Explanation

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