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

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

A. Insulin aspart (Novo Log). B. Insulin glargine (Lantus). C. Insulin lispro (Humalog). D. Insulin regular (Humulin-R).

Correct Answer is D

Explanation

Insulin regular (Humulin-R) is the only form of insulin that is safe for intravenous administration. This is because it is a short-acting insulin that has a rapid onset and peak time, and does not contain any additives or suspensions that could interfere with the infusion.

Choice A is wrong because insulin aspart (Novo Log) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.

Choice B is wrong because insulin glargine (Lantus) is a long-acting insulin that covers insulin needs for about a full day. It is not suitable for intravenous use because it forms micro-precipitates under the skin that release insulin slowly and steadily.

Choice C is wrong because insulin lispro (Humalog) is a rapid-acting insulin that is usually taken right before a meal. It is not suitable for intravenous use because it has a different amino acid sequence than human insulin.

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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

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Explanation

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Correct Answer is D

Explanation

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