Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?
A. Close the door to the client's room.
Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
B. Obtain a fire extinguisher.
Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
C. Pull the fire alarm panel.
Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
D. Remove the client from the room.
The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice D.
Choice A rationale: Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice B rationale: Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice C rationale: Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.
Choice D rationale: The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.
Similar Questions
A nurse is caring for a client who has a distal radius fracture with a short arm cast applied. Which of the following actions should the nurse take?
A. Use a hair dryer to blow hot air into the cast to relieve itching.
Choice A (Use a hair dryer to blow hot air into the cast to relieve itching) is not an answer because it can cause burns and is not a recommended intervention.
B. Perform neurovascular checks of the affected extremity every 2 hr.
The nurse should perform neurovascular checks of the affected extremity every 2 hours to monitor for any signs of compartment syndrome or impaired circulation. It is important to assess for the five Ps: pain, pulse, pallor, paresthesia, and paralysis. Using a hair dryer to relieve itching can cause burns and is not a recommended intervention. Positioning the fractured arm below the level of the client's heart can increase swelling and exacerbate pain. Immobilizing the client's fingers using a hand splint is not indicated unless there is a finger fracture or injury.
C. Position the fractured arm below the level of the client's heart.
Choice C (Position the fractured arm below the level of the client's heart) is not an answer because it can increase swelling and exacerbate pain.
D. Immobilize the client's fingers using a hand splint.
Choice D (Immobilize the client's fingers using a hand splint) is not an answer because it is not indicated unless there is a finger fracture or injury.
Full Explanation
The nurse should perform neurovascular checks of the affected extremity every 2 hours to monitor for any signs of compartment syndrome or impaired circulation. It is important to assess for the five Ps: pain, pulse, pallor, paresthesia, and paralysis. Using a hair dryer to relieve itching can cause burns and is not a recommended intervention. Positioning the fractured arm below the level of the client's heart can increase swelling and exacerbate pain. Immobilizing the client's fingers using a hand splint is not indicated unless there is a finger fracture or injury.
Choice A (Use a hair dryer to blow hot air into the cast to relieve itching) is not an answer because it can cause burns and is not a recommended intervention.
Choice C (Position the fractured arm below the level of the client's heart) is not an answer because it can increase swelling and exacerbate pain.
Choice D (Immobilize the client's fingers using a hand splint) is not an answer because it is not indicated unless there is a finger fracture or injury.
A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unit for a client who has a herniated intervertebral disk. Which of the following statements by the client indicates an understanding of the teaching?
A. "The TENS unit administers a continuous dose of pain medication."
"The TENS unit administers a continuous dose of pain medication" is not the correct answer because the TENS unit does not administer medication.
B. "I will need to charge the TENS unit for 2 hours each day."
"I will need to charge the TENS unit for 2 hours each day" is not the correct answer because the TENS unit is battery operated and does not need to be charged.
C. "The TENS unit should be applied at least 6 inches from the actual site of my pain."
"The TENS unit should be applied at least 6 inches from the actual site of my pain" is not the correct answer because the electrodes should be placed directly on the site of the pain.
D. "I should adjust the TENS unit until I feel a tingling sensation."
The correct answer is choice D, "I should adjust the TENS unit until I feel a tingling sensation." This is an appropriate statement that indicates the client understands how to use the TENS unit. The TENS unit works by sending electrical impulses to the nerves to block pain signals. The client should adjust the unit until they feel a tingling sensation, which is the desired effect.
Full Explanation
The correct answer is choice D, "I should adjust the TENS unit until I feel a tingling sensation." This is an appropriate statement that indicates the client understands how to use the TENS unit. The TENS unit works by sending electrical impulses to the nerves to block pain signals. The client should adjust the unit until they feel a tingling sensation, which is the desired effect.
"The TENS unit administers a continuous dose of pain medication" is not the correct answer because the TENS unit does not administer medication.
"I will need to charge the TENS unit for 2 hours each day" is not the correct answer because the TENS unit is battery operated and does not need to be charged.
"The TENS unit should be applied at least 6 inches from the actual site of my pain" is not the correct answer because the electrodes should be placed directly on the site of the pain.
A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?
A. Diaphoresis
Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.
B. Pupillary dilation
Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .
C. Chest pain
Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.
D. Hypotension
Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.
Full Explanation
Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.
Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.
Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .
Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.