A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action?
Turn off oxygen sources.
Put out the fire with an extinguisher.
Close the fire doors on the unit.
Notify the facility operator.
The Correct Answer is A
A. Turn off oxygen sources. After ensuring the client is safe, the priority is to reduce the risk of fire spreading, and oxygen greatly increases flammability. Turning off oxygen is a critical safety measure to prevent rapid combustion.
B. Put out the fire with an extinguisher. While extinguishing the fire is important, it should only be attempted if safe to do so and after addressing immediate dangers, such as oxygen sources and client safety.
C. Close the fire doors on the unit. This is part of containment under the RACE protocol (Rescue, Alarm, Contain, Extinguish), but it is not the first priority after rescue when oxygen is actively feeding the fire.
D. Notify the facility operator. This step corresponds to the "Alarm" phase of RACE and is essential for initiating the emergency response. However, it follows immediately after ensuring client safety and environmental hazard reduction, like turning off oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Vital signs. The client has a significantly elevated heart rate (110/min) and elevated blood pressure (178/82 mm Hg), both of which can be associated with autonomic responses in dumping syndrome. The dizziness and desire to lie down after eating are also classic symptoms. These signs reflect the body’s reaction to rapid gastric emptying and fluid shifts.
B. Prescribed diet. While a bland, soft diet is generally safe post-gastrectomy, it may not prevent dumping syndrome unless it includes specific modifications like low carbohydrate intake and small, frequent meals. However, this option alone does not directly indicate dumping syndrome.
C. Skin appearance. The client is noted to be diaphoretic and pale, which are common symptoms of dumping syndrome due to the vasomotor response and hypoglycemia that can follow rapid gastric emptying.
D. Blood glucose level. The client's fasting blood glucose dropped to 65 mg/dL, which is below the normal range. Hypoglycemia is a hallmark of late dumping syndrome, resulting from excessive insulin release after rapid carbohydrate absorption in the small intestine.
E. WBC count. The WBC count is within normal range (9,000/mm³) and does not indicate dumping syndrome or an infectious process. It is not relevant in this context.
Correct Answer is ["200"]
Explanation
Total volume to infuse = 100 mL
Infusion time = 30 minutes
- Convert infusion time to hours:
1hr = 60 minutes
30 minutes / 60 minutes/hour = 0.5 hours
- Calculate the infusion rate in mL per hour:
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hours)
= 100 mL / 0.5 hours
= 200 mL/hr
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