Nokea
The nurse observes sparks fly from a client's bathroom light. Which action should the nurse take first?
- A. Obtain a fire extinguisher
- B. Close the bathroom door
- C. Remove the client from the room
- D. Activate the fire alarm
Correct Answer: C
Rationale: Removing the client from the room prioritizes safety in a potential fire hazard. Other actions follow after ensuring client safety.
You may also like to solve these questions
The nurse is interviewing an older adult who reports a disturbed sleep pattern. The client states that he lies in bed tossing and turning and cannot fall asleep. The nurse should recommend that the client
- A. Stay in bed until he falls asleep but change positions more frequently.
- B. Take more naps earlier in the day that do not exceed one hour.
- C. Eat a meal high in carbohydrates to promote sleep.
- D. Reduce your time in bed if unable to fall asleep after 20 minutes.
Correct Answer: D
Rationale: Leaving bed after 20 minutes prevents associating bed with sleeplessness, a sleep hygiene principle. Staying in bed, napping, or high-carb meals disrupt sleep patterns.
The occupational health nurse assesses a health care worker's purified protein derivative (PPD) test and measures 11 mm of induration. The nurse should interpret this finding as
- A. A confirmatory test result for pulmonary tuberculosis.
- B. A false-negative test result.
- C. The healthcare worker requires immediate isolation using airborne isolation precautions.
- D. Further testing is required.
Correct Answer: D
Rationale: An 11 mm induration in a healthcare worker indicates a positive PPD test, suggesting TB exposure, but further testing (e.g., chest X-ray, sputum analysis) is needed to confirm active TB. It is not confirmatory for pulmonary TB, not false-negative, and isolation is premature.
A nurse is caring for a client with pneumonia who is in bilateral wrist restraints for removing multiple peripheral vascular access devices. Upon assessment, the client developed agitation and increased confusion. The nurse should take which priority action?
- A. Obtain vital signs
- B. Release restraints and provide range of motion
- C. Auscultate lung sounds
- D. Assess skin integrity under each restraint
Correct Answer: A
Rationale: Obtaining vital signs is the priority to assess for physiological causes of agitation and confusion, such as hypoxia or fever.
The nurse is conducting a staff education program on managing chemotherapy spills. Which actions should the nurse recommend be taken in the event of a chemotherapy spill? Select all that apply.
- A. Immediately evacuate clients and personnel from the area.
- B. Don personal protective equipment (PPE) before cleaning up the spill.
- C. Contain the spill using non-absorbable sheets or pads.
- D. Complete an incident report.
- E. Discard all material used in cleanup in a trash bag.
- F. Implement droplet precautions after the spill has been cleaned.
Correct Answer: A,B,C,D
Rationale: Evacuation, PPE, containment, and incident reporting are standard for chemotherapy spills. Cleanup materials require biohazard disposal, not regular trash.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.