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A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?
- A. Open the windows in the client's room to allow smoke to escape.
- B. Obtain a class C fire extinguisher to extinguish the fire.
- C. Remove all electrical equipment from the client's room.
- D. Place wet towels along the base of the door to the client's room.
Correct Answer: B
Rationale: The correct answer is B: Obtain a class C fire extinguisher to extinguish the fire. Using a class C fire extinguisher is appropriate for electrical fires, which can include fires involving electrical equipment or appliances. In this scenario, a paper fire in a trash can in the client's bathroom could potentially involve electrical components, making a class C fire extinguisher the most suitable choice. Option A, opening the windows, may help with ventilation but does not address the fire directly. Option C, removing electrical equipment, is a precautionary measure but does not address the immediate fire hazard. Option D, placing wet towels along the base of the door, is a strategy to prevent smoke from entering the room but does not extinguish the fire.
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The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?
- A. Encourage the client to take deep breaths.
- B. Provide humidified oxygen via tracheostomy collar.
- C. Suction the tracheostomy tube as needed.
- D. Change the tracheostomy dressing daily.
Correct Answer: C
Rationale: Suctioning the tracheostomy tube as needed is the most appropriate action in this scenario. When a client with a tracheostomy is unable to clear secretions by coughing, suctioning helps remove the excess secretions from the airway, ensuring proper breathing. Encouraging deep breaths (Choice A) may not effectively address the immediate need to clear secretions. Providing humidified oxygen (Choice B) can help with oxygenation but does not directly address the issue of clearing secretions. Changing the tracheostomy dressing daily (Choice D) is important for maintaining cleanliness but is not the priority when the client is unable to clear secretions.
During a health assessment, a client who takes herbal supplements makes a statement indicating an understanding of their use. Which statement is most indicative of this understanding?
- A. I use garlic for my menopausal symptoms.
- B. I use ginger when I get car sick.
- C. I take ginkgo biloba for headaches.
- D. I take echinacea to control cholesterol.
Correct Answer: C
Rationale: The correct answer is C because ginkgo biloba is commonly used to help with headaches, among other benefits. Choices A, B, and D are incorrect because garlic is not typically used for menopausal symptoms, ginger is mainly used for nausea and vomiting (not car sickness specifically), and echinacea is not known to control cholesterol.
When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45° angle
- B. Place the client's arm in a dependent position
- C. Shave excess hair from the insertion site
- D. Initiate IV therapy in the veins of the hand
Correct Answer: B
Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.
When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?
- A. Offer the client tart or sour foods.
- B. Ensure the client is sitting upright while eating.
- C. Provide soft and easily swallowable foods.
- D. Give the client thickened liquids to help with swallowing.
Correct Answer: B
Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (Choice A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (Choice C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (Choice D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.
A nurse is caring for an older adult client who becomes agitated when the nurse requests the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?
- A. You seem worried. Are you concerned someone may see you without your teeth?
- B. Don't worry, it's just for the surgery.
- C. You need to follow the instructions.
- D. The dentures need to be removed for a reason.
Correct Answer: D
Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.