A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Remove the clients from the room.
Close the door.
Extinguish the fire.
Activate the fire alarm.
The Correct Answer is A,D,B,C
A. Remove the clients from the room: Rescue any persons in immediate danger first (R in RACE).
D. Activate the fire alarm: Next, activate the alarm system to alert others (A in RACE).
B. Close the door: Confine the fire by closing doors and windows to prevent spread (C in RACE).
C. Extinguish the fire: Attempt to extinguish the fire only if it is small and you are trained to do so (E in RACE).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: It is typically defined by a drop of ≥10 mm Hg diastolic or ≥20 mm Hg systolic.
B. Orthostatic hypotension increases a client's risk of a pulmonary emboli: Orthostatic hypotension does not cause PE; they are unrelated pathophysiologies.
C. Orthostatic hypotension increases a client's risk of a fall: The drop in blood pressure on standing can cause dizziness or fainting, leading to a fall risk.
D. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: The correct threshold is ≥20 mm Hg systolic.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for correct answers:
a) Apply soft wrist restraints with assistance:
The nurse has already received a prescription from the provider for restraints due to the client actively attempting to remove medical devices. This makes the restraint medically justified and legally authorized. The restraints should be applied safely and with assistance to prevent injury during application.
c) Document the restraint application, reason, and patient response in the record:
Documentation is a legal and professional responsibility. It ensures the rationale, time, condition, interventions attempted before restraints, and client response are recorded clearly.
Rationale for incorrect answers:
b) Administer pain medication for agitation:
No indication in the note suggests pain as the cause of agitation. Medication without cause or order for agitation is inappropriate.
c) Notify the family of the restraint application:
While notifying the family is appropriate and often done, it is not the first or immediate priority once the restraint order is in place and the client is at risk of self-harm.
a) Notify charge nurse and ask for sitter assignment:
This is a helpful support measure, but after applying the restraints and documenting the care. It does not take precedence over immediate client safety and legal documentation.
b) Remove the catheter and IV to prevent further injury:
This would violate the standard of care unless ordered by the provider. The correct action is to prevent removal by using restraints safely and legally.
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