Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse’s priority?
A. Close the fire doors on the unit
Close the fire doors on the unit:Closing fire doors is a safety measure to contain smoke and flames, but activating the fire alarm is the priority to ensure a swift and comprehensive response.
B. Use a fire extinguisher to put out the fire
Use a fire extinguisher to put out the fire:While using a fire extinguisher is an important action, it should come after activating the fire alarm. The fire alarm alerts everyone to the emergency, and then the appropriate personnel can use fire extinguishers as needed.
C. Move any clients in the immediate vicinity.
Priority action during a fire: The priority in any fire situation is to ensure the safety of individuals in the immediate area. The acronym RACE is commonly used in healthcare settings to outline the steps to take in the event of a fire: Rescue anyone in immediate danger. Alarm: Activate the fire alarm. Contain the fire by closing doors. Extinguish the fire if it is small and safe to do so, or Evacuate the area if necessary.
D. Activate the fire alarm
This is also important but comes after rescuing or moving clients in immediate danger.
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Full Explanation
A. Close the fire doors on the unit:
Closing fire doors is a safety measure to contain smoke and flames, but activating the fire alarm is the priority to ensure a swift and comprehensive response.
B. Use a fire extinguisher to put out the fire:
While using a fire extinguisher is an important action, it should come after activating the fire alarm. The fire alarm alerts everyone to the emergency, and then the appropriate personnel can use fire extinguishers as needed.
C. Move any clients in the immediate vicinity:
Priority action during a fire: The priority in any fire situation is to ensure the safety of individuals in the immediate area. The acronym RACE is commonly used in healthcare settings to outline the steps to take in the event of a fire:
- Rescue anyone in immediate danger.
- Alarm: Activate the fire alarm.
- Contain the fire by closing doors.
- Extinguish the fire if it is small and safe to do so, or Evacuate the area if necessary.
D. Activate the fire alarm
This is also important but comes after rescuing or moving clients in immediate danger.
Similar Questions
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings?
A. Increased anteroposterior diameter of the chest
Increased anteroposterior diameter of the chestIn emphysema, there is often hyperinflation of the lungs and destruction of the alveolar walls, leading to loss of lung elasticity. This results in increased air trapping and a characteristic "barrel chest" appearance, with an increased anteroposterior diameter.
B. Petechiae on chest
Petechiae on chest:Petechiae are small, red or purple spots caused by bleeding into the skin. They are not commonly associated with COPD and emphysema.
C. Oxygen saturation level 96%
Oxygen saturation level 96%: Oxygen saturation level of 96% is within the normal range. While oxygen saturation can be affected in COPD, the value provided is not indicative of severe hypoxemia.
D. Respiratory alkalosis
Respiratory alkalosis:Respiratory alkalosis is not typically associated with COPD and emphysema. In fact, respiratory acidosis is more commonly seen in these conditions due to impaired gas exchange and retention of carbon dioxide.
Full Explanation
A. Increased anteroposterior diameter of the chest
In emphysema, there is often hyperinflation of the lungs and destruction of the alveolar walls, leading to loss of lung elasticity. This results in increased air trapping and a characteristic "barrel chest" appearance, with an increased anteroposterior diameter.
B. Petechiae on chest:
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not commonly associated with COPD and emphysema.
C. Oxygen saturation level 96%:
Oxygen saturation level of 96% is within the normal range. While oxygen saturation can be affected in COPD, the value provided is not indicative of severe hypoxemia.
D. Respiratory alkalosis:
Respiratory alkalosis is not typically associated with COPD and emphysema. In fact, respiratory acidosis is more commonly seen in these conditions due to impaired gas exchange and retention of carbon dioxide.
A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client’s chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding which of the following?
A. Pneumothorax
A pneumothorax occurs when air accumulates in the pleural space, causing the lung to collapse. It often presents with unilateral chest pain, dyspnea, and diminished or absent breath sounds on the affected side.
B. Atelectasis
Atelectasis refers to the collapse of alveoli in the lungs, often caused by obstruction, compression, or lack of surfactant. Symptoms include hypoxemia, diminished breath sounds, and shortness of breath.
C. Hemothorax
A hemothorax occurs when blood accumulates in the pleural space. It typically presents with chest pain, dyspnea, and diminished or absent breath sounds on the affected side.
D. Flail chest
Flail chest results from multiple rib fractures that create a free-floating segment of the chest wall. This condition causes paradoxical chest movement, where the chest wall segment moves inward during inspiration and outward during expiration.
Full Explanation
A. Pneumothorax: A pneumothorax occurs when air accumulates in the pleural space, causing the lung to collapse. It often presents with unilateral chest pain, dyspnea, and diminished or absent breath sounds on the affected side.
B. Atelectasis: Atelectasis refers to the collapse of alveoli in the lungs, often caused by obstruction, compression, or lack of surfactant. Symptoms include hypoxemia, diminished breath sounds, and shortness of breath.
C. Hemothorax: A hemothorax occurs when blood accumulates in the pleural space. It typically presents with chest pain, dyspnea, and diminished or absent breath sounds on the affected side.
D. Flail Chest: Flail chest results from multiple rib fractures that create a free-floating segment of the chest wall. This condition causes paradoxical chest movement, where the chest wall segment moves inward during inspiration and outward during expiration.
A nurse is preparing to administer amoxicillin 250 mg PO every 8 hr. The amount available is amoxicillin 125 mg tablets. How many tablets should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Full Explanation
To calculate the number of tablets that the nurse should administer with each dose, the nurse needs to use the formula:
D/H x Q = X
where D is the desired dose, H is the dose on hand, Q is the quantity of the drug, and X is the amount to give.
In this case, D is 250 mg, H is 125 mg, Q is 1 tablet, and X is unknown. Plugging these values into the formula, we get:
250/125 x 1 = X
Simplifying, we get:
2 = X
Therefore, the nurse should administer 2 tablets with each dose of amoxicillin.