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

Open nearby doors and windows when the fire alarm sounds

Attempt to extinguish the fire before evacuating clients.

Have ambulatory clients walk independently to a safe location

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

Answer and Explanation

The Correct Answer is C

A. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.

B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.

C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.

D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Apply the gown before the gloves: The gown must be applied before donning gloves to ensure that the gown fully covers the arms and torso, providing a protective barrier against contamination. Gloves are then pulled over the gown cuffs to maintain a proper seal and reduce the risk of pathogen exposure, especially with infections like Clostridium difficile.

B. The gown with the gloves on: Wearing the gown after gloves compromises the sterile barrier, allowing pathogens to contact the skin or clothing. This technique increases the risk of contamination because the gloves may not completely cover or seal the gown’s cuffs properly, which is critical in preventing the spread of infection.

C. Tuck the glove cuffs under the gown sleeves: Gloves should not be tucked under gown sleeves. Instead, gloves should cover the gown cuffs, creating a continuous protective layer. Tucking gloves under the gown can leave the wrists exposed and vulnerable to contamination, particularly when caring for clients with highly transmissible infections.

D. Push the gown sleeves up to the elbows: Pushing the sleeves up to the elbows defeats the protective purpose of the gown. It exposes the forearms to potential pathogens and bodily fluids, increasing the risk of infection transmission to both the nurse and other clients, especially when dealing with spore-forming bacteria like Clostridium difficile.

A. Encourage the client to include celery in their diet. B. Cleanse around the client's stoma with hydrogen peroxide. C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma. D. Empty the client's pouch when it is halfway full.

Correct Answer is D

Explanation

A. Encourage the client to include celery in their diet: Celery is high in fiber and stringy, which can increase the risk of obstruction in a client with a new ileostomy. Clients should avoid foods that can block the stoma until healing is complete and they are accustomed to managing their ostomy.

B. Cleanse around the client's stoma with hydrogen peroxide: Hydrogen peroxide can damage healthy skin and tissue around the stoma. The area should be cleansed gently with warm water and mild soap, avoiding harsh or irritating substances to promote skin integrity.

C. Cut the skin barrier opening 2.5 cm (1 in) larger than the stoma: The skin barrier opening should be no more than 1/8 inch (about 0.3 cm) larger than the stoma. A larger opening exposes more skin to stoma output, increasing the risk for skin irritation and breakdown.

D. Empty the client's pouch when it is halfway full: Emptying the pouch when it is about halfway full prevents the weight from pulling on the seal, reducing the risk of leaks and protecting the skin. It also maintains client comfort and reduces the chance of pouch rupture.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has a new ileostomy. Which of the following actions should the nurse include?

Correct Answer is D

Explanation

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