The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?
Call the hospital operator to determine if this is indeed a real emergency or a fire drill.
Instruct the clients' family members to stay in the visitor waiting area until further notice.
Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner.
Tell the staff to keep all clients and visitors in the client rooms with the doors closed.
The Correct Answer is D
Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.
Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.
Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.
Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This action is not the best because it does not directly evaluate the PN's wound care skills in practice. A skill checklist may not reflect the current or actual abilities of the PN, especially if it is outdated or based on self-
reporting. The charge nurse should observe the PN's performance in person to ensure that she follows the proper procedures and protocols for sterile wound care.
B) This action is the best because it allows the charge nurse to verify the PN's wound care skills and provide feedback or guidance if needed. The charge nurse has a responsibility to ensure that the PN delivers safe and effective care to the clients on the unit. By watching the PN perform sterile wound care, the charge nurse can assess her competence, confidence, and compliance with standards of practice.
C) This action is not the best because it is disrespectful and discouraging to the PN. The charge nurse should not dismiss or undermine the PN's past experience, which may have contributed to her wound care skills. The charge nurse should acknowledge and appreciate the PN's expertise, but also verify her skill level through direct
observation.
D) This action is not the best because it exposes the client to potential harm and liability. The charge nurse should not delegate a task that requires assessment and evaluation to a PN without first confirming her skill level and competency. The charge nurse should also not ask the PN to perform a task while she is busy with other duties, as this may compromise the quality and safety of care.
Correct Answer is B
Explanation
Choice A Reason: The initial administration of the analgesic is not an intervention that the charge nurse should counsel the nurse about. The opioid analgesic was prescribed by the healthcare provider and was appropriate for the postoperative pain management of the client.
Choice B Reason: The decision regarding when to call the healthcare provider is an intervention that the charge nurse should counsel the nurse about. The nurse should have called the healthcare provider as soon as the client's
respiratory rate decreased to 6 breaths/minute, which is a sign of opioid-induced respiratory depression. Waiting for another 30 minutes until the respiratory rate decreased to 4 breaths/minute could have put the client at risk of hypoxia, brain damage, or death.
Choice C Reason: The documentation of the client's respiratory rate is not an intervention that the charge nurse should counsel the nurse about. The nurse documented the client's respiratory rate accurately and timely, which is part of the standard of care and legal responsibility of the nurse.
Choice D Reason: The administration of naloxone via IV is not an intervention that the charge nurse should counsel the nurse about. Naloxone is an opioid antagonist that reverses the effects of opioids and restores normal respiration. Administering naloxone via IV is the fastest and most effective way to treat opioid-induced respiratory depression.
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