Which action should the nurse take first when discovering a fire in the client's bathroom trash can?

Leave the com to pull the fire alarm

Remove the client from their room and relocate there to a safe space

Douse the client with a fire extinguisher, using a back-and-forth motion

Close all the doors to the client's room

Answer and Explanation

The Correct Answer is B

A) Leave the room to pull the fire alarm: While pulling the fire alarm is an important step in alerting others to the fire, it is not the nurse's priority action when a fire is discovered in the client's bathroom. The immediate concern is the safety of the client. The nurse should prioritize getting the client out of harm’s way before any other actions.

B) Remove the client from their room and relocate to a safe space: This is the most appropriate first action. The nurse’s first responsibility is to ensure the client's safety. Removing the client from the immediate danger zone, which is the room with the fire, is the priority. This action helps prevent injury or death from smoke inhalation or burns. Once the client is safe, the nurse can then proceed to alert others and address the fire as needed.

C) Douse the client with a fire extinguisher, using a back-and-forth motion: This action is inappropriate because the client should never be doused with a fire extinguisher. The fire extinguisher is intended for controlling the fire, not for use on individuals. Additionally, extinguishing a fire should not take priority over ensuring the client's immediate safety by removing them from the room.

D) Close all the doors to the client's room: Closing doors can help contain the fire and prevent it from spreading, but it is not the first priority. The immediate action should focus on removing the client from the room to a safe space. After ensuring the client's safety, the nurse can then close the doors to help contain the fire while awaiting assistance.Top of FormBottom of Form

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Correct Answer is ["B","D"]

Explanation

A. Rapid loss of consciousness:
Rapid loss of consciousness is not typically a sign of hyperglycemia in type 1 diabetes. While hyperglycemia can lead to diabetic ketoacidosis (DKA) if it is severe and prolonged, which can cause confusion or stupor, rapid loss of consciousness is more often associated with severe hypoglycemia (low blood sugar), not hyperglycemia. Therefore, this is not a typical symptom of hyperglycemia in type 1 diabetes.

B. Excessive urination:
This is a correct sign of hyperglycemia. When blood sugar levels rise, the kidneys try to filter out the excess glucose, which leads to increased urination (polyuria). The kidneys cannot reabsorb all the glucose, and the excess glucose in the urine draws water with it, leading to more frequent urination.

C. Lack of appetite:
A lack of appetite is not typically associated with hyperglycemia. In fact, people with hyperglycemia or high blood sugar are often more likely to experience increased hunger (polyphagia) due to insulin resistance or the body’s inability to utilize glucose properly. A lack of appetite is more common in hypoglycemia (low blood sugar) or in conditions like diabetic ketoacidosis (DKA), where nausea and vomiting are also common. Therefore, this is not a sign of hyperglycemia.

D. Excessive thirst:
This is a correct sign of hyperglycemia. High blood sugar leads to excessive urination, which in turn causes dehydration. As a result, individuals with hyperglycemia may experience polydipsia (excessive thirst) as the body tries to compensate for the fluid loss.

E. Slow shallow respirations:
Slow, shallow respirations are typically a sign of respiratory depression and are more likely to be associated with hypoventilation or complications like diabetic ketoacidosis (DKA), rather than hyperglycemia alone. In DKA, a common complication of poorly controlled type 1 diabetes, respirations may become deep and rapid (Kussmaul respirations) in an attempt to blow off excess CO2 and correct the acidosis. Therefore, slow, shallow respirations are not a typical sign of hyperglycemia.

A. Western Blot test B. Initiation of broad-spectrum antibiotics C. Initiation of Isoniazid and Rifampin D. Antiretroviral therapy.

Correct Answer is B

Explanation

A) "Western Blot test":
. The Western Blot test is typically used to confirm HIV infection after a positive enzyme-linked immunosorbent assay (ELISA). This test is not relevant for diagnosing pneumonia, which is the most likely cause of this patient's symptoms. The patient's presentation — including dyspnea on exertion, cough with green sputum, fever, fatigue, and bilateral consolidation on the chest X-ray — points to a respiratory infection (likely pneumonia) rather than an HIV-related issue.

B) "Initiation of broad-spectrum antibiotics":
. The patient's symptoms, including dyspnea, cough with green sputum, fever, fatigue, and bilateral consolidation on chest X-ray, strongly suggest community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP). In either case, broad-spectrum antibiotics are indicated to cover a wide range of potential bacterial pathogens, especially in older adults or those with comorbidities who may be at risk for more severe infections. Immediate treatment with antibiotics is necessary to prevent complications such as respiratory failure or sepsis. Once cultures and sensitivities are obtained, the antibiotics may be adjusted based on the specific pathogen.

C) "Initiation of Isoniazid and Rifampin":
. Isoniazid and Rifampin are used to treat tuberculosis (TB), but this patient’s symptoms do not indicate TB. The patient is experiencing acute respiratory symptoms, including fever, cough with sputum production, and consolidation on chest X-ray, which are more indicative of pneumonia than of tuberculosis. Although TB could present similarly, additional testing such as a TB skin test (TST) or sputum culture for acid-fast bacilli (AFB) would be necessary before initiating antitubercular therapy. The priority intervention here is antibiotic treatment for bacterial pneumonia.

D) "Antiretroviral therapy":
. Antiretroviral therapy (ART) is used to treat HIV, but there is no indication that this patient has HIV. The symptoms presented — dyspnea, productive cough, fever, and bilateral consolidation on chest X-ray — are more consistent with an acute bacterial infection such as pneumonia rather than an HIV-related complication. ART would only be appropriate if the patient were known to have HIV and developed an opportunistic infection; however, this patient's presentation suggests a primary respiratory infection, not an HIV-related issue.

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Which action should the nurse take first when discovering a fire in the client's bathroom trash can?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes which of the following as signs and symptoms of hyperglycemia type I diabetes mellitus? Select all that apply,

Correct Answer is ["B","D"]

Explanation

An older adult client presents with dyspnea on exertion, cough with green sputum, fever, and fatigue. The nurse notes thick rhonchi/coarse crackles upon lung auscultation and the patient's chest X-ray shows bilateral consolidation. The nurse anticipates which of the following interventions?

Correct Answer is B

Explanation

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