A nurse in an extended care facility enters the room of a client and notices a fire in the trash can. Which of the following actions is the nurse's priority?
Activate the alarm.
Shut the doors and windows of the room.
Move the client to another location.
Attempt to extinguish the fire.
The Correct Answer is C
The correct answer is choice c. Move the client to another location.
Choice A rationale:
Activating the alarm is important, but the immediate priority is to ensure the safety of the client by moving them away from the fire.
Choice B rationale:
Shutting the doors and windows can help contain the fire, but it should be done after ensuring the client is safe.
Choice C rationale:
Moving the client to another location is the priority action to protect them from harm. Ensuring the client’s safety is the first step in any emergency situation.
Choice D rationale:
Attempting to extinguish the fire is important, but it should be done after the client is safely moved to another location.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for a client with terminal cancer who expresses a desire to discontinue enteral tube feedings, the nurse's priority is to ensure that the client's wishes are respected and appropriate steps are taken. The most suitable action is:
c) Explain the process for completing a living will.
A living will is a legal document that outlines a person's preferences regarding medical treatment in the event they are unable to communicate their wishes. In this situation, the client can express their desire to forgo enteral tube feedings through a living will, ensuring that their wishes are documented and legally recognized.
The other options may not be as appropriate:
a) Request the facility chaplain to visit the client:While spiritual and emotional support is important, the immediate concern is ensuring the client's autonomy in decision-making regarding medical interventions.
b) Ask the client to sign an informed consent form:Informed consent typically pertains to specific medical procedures, and discontinuing enteral tube feedings is more aligned with the broader context of advance care planning.
d) Complete an against medical advice form:This form is typically used when a patient refuses a recommended treatment against the medical team's advice. However, in this case, the client is expressing their own treatment preferences, and the focus should be on facilitating advance care planning and documentation.
Correct Answer is A
Explanation
The correct answer is choice A. A client who has a rigid abdomen with manifestations of shock should receive treatment priority in this situation. In a bombing incident, clients with life-threatening injuries, such as those with uncontrolled bleeding, airway compromise, or shock, should receive immediate attention. A rigid abdomen may indicate internal bleeding, which is a medical emergency requiring prompt intervention. Manifestations of shock, such as tachycardia, hypotension, and altered level of consciousness, indicate poor tissue perfusion and require immediate intervention. The other clients described in the question have less severe injuries and can wait for treatment while more critical injuries are addressed first. A femur fracture with a 2+ pedal pulse indicates adequate circulation to the extremity, superficial partial-thickness burn injuries over 5% of the body are not life-threatening, and an ambulatory client with manic behavior does not have immediate medical needs.
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