A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

Attempt to extinguish the fire before evacuating clients.

Aim the spray of the fire extinguisher at the top of the fire.

Open nearby doors and windows when the fire alarm sounds.

Have ambulatory clients walk independently to a safe location

Answer and Explanation

The Correct Answer is D

Rationale:

A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.

B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.

C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.

D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale:

• Seizures: The client’s significantly elevated T3 (230 ng/dL), T4 (3.4 ng/dL), and TSI (150%) levels, along with symptoms such as anxiety, heat intolerance, insomnia, and irritability, suggest hyperthyroidism and risk for thyroid storm. This hypermetabolic state can lead to neurological complications including seizures due to increased cerebral excitability.

• Pneumonia: The client has no respiratory distress, maintains a clear airway, has normal respiratory rate and oxygen saturation, and shows no pulmonary abnormalities. There are no signs to suggest a risk for infection or hypoventilation.

• Paralytic ileus: There are no gastrointestinal symptoms such as abdominal distension, absent bowel sounds, or nausea. The client has normal GI function with a good appetite and soft brown stools, ruling out risk of ileus.

• thyroid storm: The clinical picture unplanned weight loss, exophthalmos, goiter, hyperreflexia (suggested by irritability), and insomnia aligns with Graves’ disease and severe thyrotoxicosis. Surgery can precipitate a thyroid storm if thyroid hormone levels are not well controlled beforehand.

• hypoparathyroidism: While this is a known risk after thyroidectomy due to parathyroid injury, the client has not yet had surgery at the time of the lab results and symptoms. No signs of hypocalcemia (e.g., tingling, cramps) are present either.

• laryngeal nerve damage: This is an intraoperative complication, generally presenting as hoarseness or voice changes. There are no findings suggesting vocal cord involvement, and it would not lead to seizures.

A. Chlorhexidine B. Hydrogen peroxide C. Bleach D. Isopropyl alcohol

Correct Answer is C

Explanation

Rationale:

A. Chlorhexidine: Chlorhexidine is primarily used as an antiseptic for skin preparation or wound cleaning. It is not effective for disinfecting surfaces contaminated with bloodborne pathogens such as HIV.

B. Hydrogen peroxide: While hydrogen peroxide has disinfectant properties, it is less effective than bleach against a broad range of viruses, especially in situations involving blood spills where a higher-level disinfectant is recommended.

C. Bleach: A 1:10 dilution of household bleach (sodium hypochlorite) is the recommended solution for disinfecting surfaces contaminated with blood due to its strong virucidal properties. It effectively kills HIV and other bloodborne pathogens on environmental surfaces.

D. Isopropyl alcohol: Isopropyl alcohol has limited effectiveness against organic matter like blood and is not recommended for disinfecting blood-contaminated surfaces. It evaporates quickly and may not provide adequate contact time for complete disinfection.

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A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

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