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 D
Explanation
A. Able to unzip a zipper. This fine motor skill typically develops closer to age 2 to 3 years. At 15 months, most toddlers do not yet have the dexterity required to manipulate clothing fasteners.
B. Builds a tower of 4 cubes. A 15-month-old can usually build a tower of 2 to 3 cubes, while building a tower of 4 or more cubes is more typical around 18 to 24 months.
C. Throws a ball without falling. While some toddlers may attempt to throw a ball, doing so without falling is more characteristic of children around 18 months or older as balance improves.
D. Walks without help. This is an expected milestone by 12 to 15 months. Most toddlers at 15 months are able to walk independently, though gait may still be wide-based and unsteady.
Correct Answer is A
Explanation
A. "I will hang a new bag of TPN and IV tubing every 24 hours." This is the correct action. TPN solutions are high in glucose and lipids, which create an ideal environment for bacterial growth. Changing the bag and tubing every 24 hours reduces the risk of infection and sepsis, especially in clients with central lines.
B. "I will obtain the client's weight every other day." Weight should be monitored daily in clients receiving TPN to assess for fluid status, nutritional progress, and potential complications like fluid overload or retention.
C. "I will monitor the client's blood glucose level every 8 hours." Clients receiving TPN require more frequent glucose monitoring, typically every 4 to 6 hours, especially when therapy is initiated, due to the high dextrose content that can cause hyperglycemia.
D. “I will increase the rate of the TPN infusion to ensure the correct amount is given." TPN infusion rates should never be adjusted independently by a nurse. Changes must be made only with a provider’s order, as improper rate adjustments can lead to electrolyte imbalances, hyperglycemia, or fluid overload.
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