Question

A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client’s room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

Answer 1

Correct Answers:

Activate the alarm outside the client’s room

Rationale :

🟡 After removing the client (Rescue), the next RACE step is Alarm to ensure rapid facility-wide response.

🟡 Activating the alarm alerts fire personnel and initiates the emergency fire protocol.

🟡 Prompt alarm activation prevents delays in evacuation and limits fire spread.

🟡 Staff must know that alarm activation comes before attempting any containment steps.

🟡 Following correct sequence ensures safety for clients and staff through coordinated response.

Turn off electrical equipment

🟡 Turning off equipment is part of Contain, but comes AFTER activating the alarm.

🟡 Doing this first delays emergency notification.

Use a Class A extinguisher

🟡 Extinguishing is the final RACE step and should occur only after alarm activation.

🟡 Using an extinguisher too early puts staff at unnecessary risk.

Close the door

🟡 Closing the door is also part of Contain, a later step.

🟡 It should not replace the immediate need to trigger the alarm.

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Answer 2

Correct Answers:

Use of the Braden scale for clients who are immobile

Rationale :

🌟 The Braden scale is the validated tool used to identify clients at high risk for pressure injuries.

🌟 It evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

🌟 Immobile clients are the highest-risk group and must be formally assessed.

🌟 Documentation of Braden scoring allows nurses to plan preventive interventions.

🌟 Using a standardized assessment tool ensures consistent monitoring across caregivers.

Daily weighing of clients with heart failure

🌟 Weight monitoring assesses fluid status, not skin breakdown risk.

🌟 It is irrelevant to pressure injury prevention.

Incentive spirometry for postoperative clients

🌟 Incentive spirometry prevents atelectasis, not pressure injuries.

🌟 It does not help identify clients at risk for skin breakdown.

Pain scale documentation for dementia

🌟 Pain scoring aids in comfort management but does not assess skin integrity risk.

🌟 Dementia may increase risk, but pain scale alone provides no Braden-related data.

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Answer 3

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

♦ The first step is to pull the pin, unlocking the extinguisher for use.

♦ Directing the nozzle at the base of the fire attacks the fuel source rather than the flames.

♦ Squeezing the handle releases the extinguishing agent needed to suppress the fire.

♦ Moving side-to-side ensures even coverage and extinguishes all active areas.

♦ This standard PASS method provides the most effective and safest extinguisher operation.

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Answer 4

Correct Answers:

Encourage the use of an incentive spirometer

Rationale :

🔷 Incentive spirometers are cost-effective tools that prevent postoperative atelectasis, reducing complications and hospital costs.

🔷 Encouraging self-use promotes client independence, decreasing the need for additional respiratory therapy resources.

🔷 This intervention minimizes the risk of pneumonia, which is expensive to treat.

🔷 It requires no additional equipment aside from the spirometer already provided, maximizing resource efficiency.

🔷 Using preventive strategies reduces overall healthcare utilization, making it a highly cost-effective nursing practice.

Have families assist with ambulation

🔷 Family assistance is unsafe because ambulation requires trained staff to prevent falls.

🔷 Client safety takes priority over cost savings.

Turn client every 4 hr

🔷 Turning every 4 hours increases risk for pressure injuries, which are costly to treat.

🔷 Immobile clients require repositioning every 2 hours, not 4.

Provide IV pain medication

🔷 IV analgesics are more expensive and require more monitoring than oral options when appropriate.

🔷 Not a cost-effective pain management approach.

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Answer 5

Correct Answers:

Log off the computer to attend the client’s needs

Rationale :

🟢 Logging off protects electronic protected health information (ePHI) from unauthorized access.

🟢 This action complies with HIPAA regulations, which require secure handling of client data.

🟢 Leaving a session open risks exposure of confidential medical information.

🟢 Logging off ensures another staff member cannot accidentally enter incorrect data under the wrong chart.

🟢 It maintains ethical and legal standards for protecting client privacy and confidentiality.

Leave the computer in the hallway

🟢 Leaving the workstation unattended exposes PHI to public view, violating HIPAA.

🟢 It does not secure client information.

Complete documentation before attending the client

🟢 Client safety and needs must come first before completing documentation.

🟢 Delaying care for paperwork is unsafe practice.

Minimize the screen

🟢 Minimizing does not prevent unauthorized access; the information is still open.

🟢 Does not meet legal privacy requirements.

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Answer 6

Correct Answers:

Record the facts about the incident in the medical record

Rationale :

🟣 The medical record must contain objective, factual information about the client’s condition and the care provided.

🟣 The nurse must document the injury, assessment, and interventions related to the superficial burn.

🟣 Legal and clinical accuracy requires recording only the facts, not opinions or blame.

🟣 This documentation ensures continuity of care by informing future providers of the client’s status and treatment.

🟣 The incident report itself remains separate and is NOT mentioned in the medical record.

Document that an incident report was completed

🟣 Mentioning an incident report in the chart introduces legal liability and is prohibited.

🟣 The report is an internal facility document only.

Place a copy of the incident report in the medical record

🟣 Incident reports are not part of the medical record and must be kept separate.

🟣 Storing them in the chart violates facility and legal standards.

Provide the family with a copy

🟣 Families do NOT receive incident reports—they are internal quality improvement tools.

🟣 Providing a copy creates legal concerns and violates policy.

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Answer 7

Correct Answers:

A client who requires initial education about blood glucose monitoring

Rationale :

💠 Initial teaching requires assessment, evaluation, and clinical judgment, which fall under RN scope.

💠 Teaching a new skill demands the RN’s ability to determine readiness to learn and adapt instruction.

💠 Only RNs can provide the first episode of teaching because it influences long-term self-management.

💠 Follow-up teaching may be delegated, but initial education cannot.

💠 Ensuring proper technique prevents complications like hypoglycemia or improper insulin use.

Irrigation of an indwelling catheter

💠 Catheter irrigation is within the scope of LPN/LVN, not exclusive to RN.

💠 It does not require advanced teaching or assessment.

Enteral feeding

💠 Enteral feeding can be safely performed by an LPN/LVN once the initial assessment is done.

💠 It is routine and does not require RN-only decision making.

Tracheostomy suctioning

💠 Suctioning is within the skill set of an LPN/LVN, depending on facility policy.

💠 It does not require initial high-complexity judgment.

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Answer 8

Correct Answers:

Wearing a mask when assisting the client to rise to the restroom

Rationale :

🔵 Droplet precautions require a mask within 3 feet of the client because droplets travel short distances.

🔵 Direct care activities like helping the client ambulate place the nurse in exposure range.

🔵 Masks protect against pathogens transmitted by coughing, sneezing, and talking.

🔵 This follows CDC guidelines for diseases such as influenza and meningitis.

🔵 Wearing a mask reduces risk of contamination for both nurse and other clients.

Positive airflow room

🔵 Positive pressure is for protective isolation, not droplet precautions.

🔵 It would spread droplets outward, increasing infection risk.

Wear a gown for meal delivery

🔵 Gowns are needed for contact precautions, not droplet.

🔵 Droplet requires primarily a mask.

Negative airflow room

🔵 Negative pressure is for airborne pathogens (TB, measles, varicella).

🔵 Droplet diseases do not require this level of isolation.

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Answer 9

Correct Answers:

Social worker

Rationale :

🔶 Social workers coordinate community resources, including transportation services for clients who live alone.

🔶 They can arrange medical transport, community shuttles, or disability transport as appropriate.

🔶 The social worker assesses the client’s home situation and support needs, ensuring safe discharge.

🔶 They help secure resources such as home help, equipment, or follow-up services to promote independent recovery.

🔶 Their role ensures barriers to postoperative care, including transportation, are addressedbefore discharge.

Occupational therapist

🔶 OT focuses on ADLs and home safety, not transportation coordination.

🔶 They recommend adaptive equipment but do not arrange community services.

Physical therapist

🔶 PT focuses on mobility and strengthening, rather than transportation resources.

🔶 They assist with ambulation training, not discharge logistics.

Dietitian

🔶 Dietitians manage nutritional needs, which do not address transportation concerns.

🔶 Not involved in arranging community services.

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Answer 10

Correct Answers:

A client who has audible wheezes

Rationale :

💠 Audible wheezing indicates airway narrowing, posing an immediate threat to oxygenation.

💠 Clients with airway compromise are always the first priority under ABC principles.

💠 Wheezing may indicate asthma, anaphylaxis, or obstruction, all requiring rapid intervention.

💠 Early assessment prevents deterioration into respiratory failure.

💠 This condition presents a greater risk than musculoskeletal injuries or localized pain.

Dislocated shoulder

💠 Painful but not life-threatening, and the airway is intact.

💠 This client is stable compared to someone with respiratory compromise.

5 cm laceration

💠 A laceration is concerning but does not threaten airway or breathing.

💠 Can wait compared to a respiratory priority.

RLQ abdominal pain

💠 May indicate appendicitis but is not immediately life-threatening.

💠 Priority remains airway: wheezing comes first.

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QLexNursing

1 :
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client’s room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

2 :
A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document to identify clients who are at risk for skin breakdown?

3 :
A nurse is evaluating an assistive personnel's (AP) use of a fire extinguisher. In which order should the AP complete the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

4 :
A nurse is caring for a group of clients who are postoperative. Which of the following actions demonstrates appropriate, cost-effective strategies in providing nursing care?

5 :
A nurse is documenting the care of a client in the computer when she is called to another client’s room. Which of the following actions should the nurse take?

6 :
A nurse in a long-term care facility is completing an incident report for a client who received a superficial burn from a heating pad. Which of the following actions should the nurse take?

7 :
A nurse is receiving change-of-shift report about four clients. Which of the following clients should the nurse ask the charge nurse to reassign to an RN?

8 :
A nurse in a long-term care facility is caring for a client who is on droplet precautions. Which of the following actions by the nurse is appropriate?

10 :
A nurse working in a provider’s office is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?

QLexNursing

1 : A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client’s room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

2 : A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document to identify clients who are at risk for skin breakdown?

3 : A nurse is evaluating an assistive personnel's (AP) use of a fire extinguisher. In which order should the AP complete the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

4 : A nurse is caring for a group of clients who are postoperative. Which of the following actions demonstrates appropriate, cost-effective strategies in providing nursing care?

5 : A nurse is documenting the care of a client in the computer when she is called to another client’s room. Which of the following actions should the nurse take?

6 : A nurse in a long-term care facility is completing an incident report for a client who received a superficial burn from a heating pad. Which of the following actions should the nurse take?

7 : A nurse is receiving change-of-shift report about four clients. Which of the following clients should the nurse ask the charge nurse to reassign to an RN?

8 : A nurse in a long-term care facility is caring for a client who is on droplet precautions. Which of the following actions by the nurse is appropriate?

10 : A nurse working in a provider’s office is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?

1 :
A nurse is reinforcing teaching with staff members about the protocol for extinguishing a fire in a trash can in a client’s room. After removing the client from the room, which of the following actions should the nurse instruct the staff members to take next?

2 :
A nurse is reviewing documentation on a group of clients as part of a quality improvement initiative. Which of the following actions should the nurse document to identify clients who are at risk for skin breakdown?

3 :
A nurse is evaluating an assistive personnel's (AP) use of a fire extinguisher. In which order should the AP complete the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

4 :
A nurse is caring for a group of clients who are postoperative. Which of the following actions demonstrates appropriate, cost-effective strategies in providing nursing care?

5 :
A nurse is documenting the care of a client in the computer when she is called to another client’s room. Which of the following actions should the nurse take?

6 :
A nurse in a long-term care facility is completing an incident report for a client who received a superficial burn from a heating pad. Which of the following actions should the nurse take?

7 :
A nurse is receiving change-of-shift report about four clients. Which of the following clients should the nurse ask the charge nurse to reassign to an RN?

8 :
A nurse in a long-term care facility is caring for a client who is on droplet precautions. Which of the following actions by the nurse is appropriate?

10 :
A nurse working in a provider’s office is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first?