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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Use tubing that does not have a filter in the drip chamber. Blood transfusion tubing must have a filter to trap clots, cellular debris, and other particulates, ensuring the safe administration of blood products.
B. Use an IV catheter that is at least 24-gauge. A larger bore catheter (18- to 20-gauge) is preferred for blood transfusions to reduce the risk of hemolysis and allow adequate flow. A 24-gauge is too small for standard transfusion protocols.
C. Attach a single line administration set. A Y-type tubing set is typically used, allowing for connection to both the blood product and normal saline. This setup enables flushing before and after the transfusion and provides a safe delivery system.
D. Prime the tubing with 0.9% sodium chloride. Only 0.9% sodium chloride (normal saline) should be used to prime the tubing, as it is compatible with blood products and prevents hemolysis or clot formation. Dextrose or other solutions can cause serious reactions.

A. "The proxy should manage legal issues for the client." B. "The proxy can make treatment decisions if the client is under anesthesia." C. The proxy can make financial decisions if the need arises." D. The proxy should make health care decisions for the client regardless of the client's ability to do so "

Correct Answer is B

Explanation

A. "The proxy should manage legal issues for the client." Legal matters are outside the scope of a health care proxy’s role. The proxy is authorized only to make medical decisions and does not handle legal or court-related concerns on behalf of the client.
B. "The proxy can make treatment decisions if the client is under anesthesia." The health care proxy is activated when the client is temporarily or permanently incapacitated, such as during surgery under anesthesia. At that point, the proxy can make treatment decisions aligned with the client’s values and previously expressed wishes.
C. "The proxy can make financial decisions if the need arises." Financial decisions are the responsibility of a financial power of attorney, not a health care proxy. A DPAHC limits the proxy’s authority strictly to medical and treatment-related decisions.
D. "The proxy should make health care decisions for the client regardless of the client's ability to do so." The health care proxy is not active while the client is competent and able to make decisions. The proxy only assumes responsibility when the client lacks decision-making capacity due to illness, unconsciousness, or cognitive impairment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). Which of the following information should the charge nurse include?

Correct Answer is B

Explanation

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