Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse enters a client's room and discovers a smoldering fire in the drapes. After moving clients to a safe location, which of the following actions should the nurse take next?
A. Use an extinguisher to put out the fire.
B. Pull the fire alarm.
After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems. Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning off electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.
C. Close the doors to client rooms.
D. Turn off any electrical equipment in the room.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Fundamentals 2019 with NGN - Proctored Exam 2. Take the full exam now
Full Explanation
After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.
Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning off electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.
Similar Questions
A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea.
(Arrange the steps, placing them in the order of performance. Use all the steps.)
A. Determine the probability of intervention-related complications.
B. Review the potential benefits and consequences of each intervention.
C. Select an intervention that provides the greatest benefit and least risk.
D. Identify possible nursing interventions that address the client's nausea.
Full Explanation
When caring for a client who is nauseated and unable to eat after taking an antibiotic, the nurse should first identify possible nursing interventions that address the client's nausea. The nurse should then review the potential benefits and consequences of each intervention. The nurse should determine the probability of intervention-related complications. Finally, the nurse should select an intervention that provides the greatest benefit and least risk to the client.
A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuff to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)
A. Palpate the brachial pulse site.
B. Discontinue palpation of the brachial pulse.
C. Inflate the blood pressure cuff to 30 mm Hg beyond where the brachial pulse was last felt.
D. Deflate the blood pressure cuff slowly until the brachial pulse is detected.
Full Explanation
First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inflate the blood pressure cuff to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deflate the blood pressure cuff slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.
A nurse is caring for a client who has an ileostomy.
Nurses' Notes
Day 1:
- Client is alert and oriented.
- ileostomy stoma is pink.
- Stoma draining moderate brown liquid stool.
- Client will not look at the stoma.
- Client states they are not interested in learning about stoma care.
- Intake: 2,200 mL over the last 24 hr
- Urine output: 1,200 ml over the last 24 hr
Day 2:
- ileostomy pouch changed. Skin surrounding the stoma is reddened and appears irritated
- initiated a request for a referral to an ostomy nurse.
- intake. 1,600 mL over the last 24 hr
- Urine output: 650 mL over the last 24 hr
The nurse is reviewing the client's medical record. Select the information that requires intervention by the nurse.
A. Ileostomy stoma is pink.
A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings.
B. Stoma draining moderate brown liquid stool.
A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings.
C. Client will not look at the stoma.
The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention.
D. Client states they are not interested in learning about stoma care
The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention.
E. Intake: 2,200 mL over the last 24 hr
An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
F. Skin surrounding the stoma is reddened and appears iritated
f) Skin surrounding the stoma is reddened and appears irritated. The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage. Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
G. Urine output: 650 mL over the last 24 hr
An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Full Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
