ATI Study NXLEX Quiz
A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hour night shift? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
90 Follow these steps for the conversion of oz to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL = 3 x 1 oz/X mL 1 oz/30 mL = 3 oz/X mL X = 90
A nurse is reinforcing teaching with a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? I'll wear nonsterile gloves." "I'll use adhesive remover each time." "I'll take my pain pill after I change the dressing." "I'll fold the dressing with the soiled surface facing outward."
A. "I'll wear nonsterile gloves." Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile, unless the provider specifically prescribes sterile gloves for dressing changes.
A nurse is measuring a client's blood pressure. The nurse notes that the systolic reading is typical for the client, but the diastolic reading is considerably higher than the client's usual baseline. Which of the following errors in blood-pressure measurement is a possible cause of a falsely elevated result? Deflating the cuff too slowly Using a bladder cuff that is too wide Inflating the cuff insufficiently Holding the stethoscope too tightly against the skin
A. Deflating the cuff too slowly Deflating the cuff too slowly can falsely elevate the diastolic pressure. Deflating it too quickly can cause a falsely low systolic and falsely high diastolic reading.
A nurse is collecting data from a 5-year old client during a routine examination. Which of the following activities should the nurse expect the child to perform? Ride a bicycle with training wheels Climb a tree Throw and catch a ball Play a musical instrument
A. Ride a bicycle with training wheels By the age of 5 years, preschoolers should be able to ride a bicycle with training wheels, skip and jump rope, and print letters and numbers. They should also be able to demonstrate creativity and imagination.
A nurse is preparing to assist an older adult client with ambulation; the client has been on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? Use a gait belt during ambulation Ensure the client is wearing socks before ambulating Instruct the client to sit on the edge of the bed for 15 seconds before ambulating Walk 2 feet behind the client during ambulation
A. Use a gait belt during ambulation The nurse should use a gait belt to keep the client's center of gravity at midline and to decrease the risk of a fall.
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Encourage the child to cough frequently to clear congestion from anesthesia Place a heating pad on the child's neck for comfort Administer analgesics to the child on a routine schedule throughout the day and night Provide the child with ice cream when oral intake is initiated
Administer analgesics to the child on a routine schedule throughout the day and night
A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? Supine Lateral Fowler's Trendelenburg
C. Fowler's Sitting upright promotes full expansion of both lungs and facilitates ventilation and perfusion.
A nurse is collecting data from a client who has asthma and reports several food allergies. Which of the following actions should the nurse perform first? Document the client's food allergies in the medical record Ask the client to identify the specific food allergies Monitor the client for indications of anaphylaxis Have epinephrine available for administration
Correct Answer: B. Ask the client to identify the specific food allergies The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to collect data about the client's allergies and identify the specific allergens so that the nurse can ensure those foods are not offered to the client during meals.
A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? "Social services can contact various community resources that will be helpful." "I will review the care plan to make any necessary changes." "Let's set up a meeting time with the doctor to discuss your options for home care." "I will make a list of things we need to do before discharge."
Correct Answer: C. "Let's set up a meeting time with the doctor to discuss your options for home care." With family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family help determine outcomes and goals. Setting up a meeting to discuss this option with the provider will give the family a sense of autonomy and foster the family-centered nursing environment.
A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when explaining the procedure to the client? Make eye contact with the interpreter Break sentences into shorter segments to allow time for interpretation Ensure the interpreter and the client speak the same dialect Speak in a loud tone of voice
Ensure the interpreter and the client speak the same dialect The interpreter should speak the same dialect as the client and should also understand any cultural norms or practices that could make the interaction uncomfortable.
During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing clients' information? In the unit medication room Outside the door of a client's room In the cafeteria during a break In the hallway near the nurses' station
In the unit medication room
A nurse is collecting data about a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? Secondary source data Experiential data Primary source data Quantitative data
Information provided by someone other than the client is secondary source data. Secondary DATA
A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take? Place the client supine Keep both side rails up Raise the level of the bed Inspect the client's mouth using a finger sweep
Raise the level of the bed The nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of self-injury.
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? Attempting to increase the clients' self-motivation Keeping detailed records of each client's progress Testing client learning after each teaching session Avoiding discussing topics that might cause client anxiety
A. Attempting to increase the clients' self-motivation Motivation to learn is important for improving a client's commitment to achievement of a health goal, as well as for increasing the amount and speed of learning.
A nurse is reinforcing teaching with a client about how to obtain a capillary finger-stick blood sample. Which of the following actions by the client requires the nurse to intervene? Elevates the finger above heart level Rubs the fingertip with an alcohol pad Punctures the side of the fingertip Wraps the finger in a warm cloth
A. Elevates the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads as follows: "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make? "Lunch trays should be here within the hour." "I am going to listen to your abdomen." "I'll get you some water to drink." "I would wait a bit to avoid feeling sick."
B. "I am going to listen to your abdomen." Clients often experience nausea and vomiting after surgery because of delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.
A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A client who has multiple sclerosis and uses a wheelchair A client who has end-stage cirrhosis A client who has hemiplegia due to a stroke A client who has cancer and receives weekly radiation therapy
B. A client who has end-stage cirrhosis A client who has end-stage cirrhosis likely has a life expectancy of ≤6 months. Therefore, this client is eligible for hospice services.
A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? Complete an incident report Check the client for injuries Make sure the client has skid-free footwear Remind the client to ask for help with getting out of bed
B. Check the client for injuries The first action the nurse should take using the nursing process is to evaluate the client for any injuries or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention.
A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform first after the transfer? Administer pain medication Check the client's vital signs Instruct the client to use the incentive spirometer every hour Provide ice chips per provider prescription
B. Check the client's vital signs The greatest risk to this client is an injury from vital signs becoming unstable such as with hypotension and respiratory depression, after having received anesthesia and medication. Therefore, the nurse should first check the client's vital signs and compare them with the readings during the PACU stay.
A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? Obtain an audiology referral Document this as an expected finding Irrigate the ear with warm water Document mild inflammation
B. Document this as an expected finding The light the otoscope reflects off the tympanic membrane is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant.
A nurse is collecting data from a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. The nurse should identify that this manifestation is consistent with which of the following eye disorders? Retinopathy Glaucoma Cataracts Macular degeneration
B. Glaucoma An obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to increased intraocular pressure, resulting in damage to the eye.
A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy? Holding a community clinic to administer influenza immunizations Screening groups of older adults in nursing care facilities for early influenza manifestations Educating parents of young children about the dangers of influenza Finding rehabilitation programs for older adults who have complications from influenza
B. Screening groups of older adults in nursing care facilities for early influenza manifestations Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.
A nurse is preparing to collect data about the function of a client's trigeminal nerve or cranial nerve (CN) V. Which of the following items should the nurse gather for the test? Sugar Coffee Cotton wisps Snellen chart
C. Cotton wisps The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to test recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of CN V, the nurse should ask the client to clench the teeth.
A nurse is talking with a client whose provider recently informed him that he has terminal pancreatic cancer. When the client expresses that he understands the full impact of this diagnosis, the nurse should identify that he is in which of the following stages of dying? Anger Bargaining Depression Acceptance
C. Depression During the stage of depression, the client has realized the full impact of the loss and might express hopelessness and despair.
A nurse is caring for a client who is dehydrated. Which of the following laboratory values should the nurse expect for this client? BUN 18 mg/dL Capillary refill 1.5 seconds Hct 55% Urine specific gravity 1.001
C. Hct 55% An elevated hematocrit indicates dehydration. Other manifestations include a weak pulse, tachycardia, hypotension, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.
At a well-child visit, a nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse report to the provider? Turning from her side to her back Laughing and babbling when content Head lagging when the parent pulls the infant up to sit Bringing objects from her hand to her mouth
C. Head lagging when the parent pulls the infant up to sit Between 4 and 6 months, there should be no head lag when the parent pulls the infant to a sitting position. Between the ages of 6 months and 8 months, the infant should be able to sit without support.
A nurse is collecting data from a client who is experiencing stress over a near fall out of bed. Which of the following physiological responses should the nurse expect to observe due to the client's fight-or-flight response? Decreased respiratory rate Pinpoint pupils Increased blood pressure Bronchiolar construction
C. Increased blood pressure The nurse should expect a client who is experiencing the fight-or-flight response to manifest increased arterial blood pressure, heart rate, and cardiac output due to the arousal of the central nervous system.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube Position the client on his right side Insert the tip of the tubing 8 cm (3.1 in) Hold the enema container 61 cm (24 in) above the rectum
C. Insert the tip of the tubing 8 cm (3.1 in) The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa.
A nurse is reinforcing teaching with a group of unit nurses about the experiences of clients who are having surgery. Which phase of care begins with transferring the client to the surgical suite table and ends with the transfer to PACU? Preoperative Postoperative Intraoperative Admission
C. Intraoperative Intraoperative care begins when the client is transferred to the surgical suite table and ends when the client is admitted to the PACU.
A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? Return the unused portion of the medication to the pharmacy Dispose of the wasted medication into a sharps container Record the amount of medication wasted on the controlled substance inventory record Ask an assistive personnel (AP) to witness the wasting of the controlled substance
C. Record the amount of medication wasted on the controlled substance inventory record Two nurses should sign the controlled substance inventory record to document the amount of medication wasted.
A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse should identify that which of the following nutrients will be affected by the lack of salivary amylase? Fat Protein Starch Fiber
C. Starch Salivary amylase begins the process of digestion in the mouth with the initial break of down starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase.
A nurse is assisting with the admission of a client who will undergo a craniotomy. During the planning phase of the nursing process, to which of the following areas should the nurse contribute? Correct Answer: A. Establishing client outcomes Establishing client outcomes Collecting information about past health problems Determining whether the client has met goals Identifying the client's specific health problems
Correct answer: (A) Establishing client outcomes. The planning phase of the nursing process includes developing goals and outcomes that help the nurse contribute to the client's plan of care.
A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. The nurse should identify that which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Using clean technique to perform the procedure Applying suction while inserting the catheter Lubricating the suction catheter with an oil-based lubricating jelly Administering high-flow oxygen prior to the procedure
D. Administering high-flow oxygen prior to the procedure The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via resuscitation bag to the client before suctioning to reduce the risk of hypoxia.
A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? Clean the incision from bottom to top Apply sterile gloves prior to opening the dressing packages Remove the tape by pulling away from the wound Clean the drain site from the center outward
D. Clean the drain site from the center outward The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound.
A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? Diarrhea Pupillary constriction Flushing Grimacing
D. Grimacing Besides the client's self-report of pain, facial expressions such as grimacing, clenching the jaw, and lip biting can be indications of pain.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Auscultate for the blood pressure at the dorsalis pedis artery Measure the blood pressure with the client sitting on the side of the bed Place the cuff 7.6 cm (3 in) above the popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh
D. Place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the nurse to place the bladder of the cuff when measuring a lower-extremity blood pressure.
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? Instruct the client to defecate into the toilet bowl Transfer the specimen to a sterile container Refrigerate the collected specimen Place the stool specimen collection container in a biohazard bag
D. Place the stool specimen collection container in a biohazard bag The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification and to prevent contamination with microorganisms.
A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? Right task Right circumstance Right person Right communication
D. Right communication The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.
A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? Gloves Gown Eyewear Mask
Gloves According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least
A nurse is collecting data about a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? Popliteal Posterior tibial Dorsalis pedis Femoral
dorsal pedis The dorsalis pedis pulse is located on the top of the foot, following the groove between the tendons of the great toe. It is best felt by putting the fingertip between the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is congenitally absent in some clients.
A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first? Use the pain scale to determine the client's pain level Discuss the adverse effects of pain medication with the client Obtain the client's vital signs Check the client's allergies
A. Use the pain scale to determine the client's pain level The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority, when caring for this client. These levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow's hierarchy of needs, the nurse should review physiological needs first and then follow the remaining hierarchal levels. However, the nurse should consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific situation.
A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task for her age group? "I am comfortable with my decision to choose a lifelong partner." "I think I have done a good job with my children since they are all independent now." "As I look back over my life, I can see that I have achieved most of the goals I set for myself." "I love my work so much that I don't want to think about retirement."
B. "I think I have done a good job with my children since they are all independent now." According to Erikson, the developmental task for middle adults is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching. The client talking about helping her children achieve independence reflects that she has accomplished this developmental task.
A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh
B. Lower abdomen The nurse should secure with tape the client's urinary catheter to the lower abdomen or the upper inner aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.
A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "My parents are retired, and they have come to help with our children." "I am going to ask my husband to go to counseling with me." "I keep having nightmares about my upcoming surgery." "My girlfriends bought me a nice wig."
C. "I keep having nightmares about my upcoming surgery." The nurse should recognize that nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk of experiencing psychological distress.
A nurse is reinforcing teaching with a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? Eggs Soybeans Lentils Yogurt
C. Lentils Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds.
A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Fifth intercostal space just medial to the midclavicular line Second intercostal space to the left of the sternum Fifth intercostal space to the left of the sternum Second intercostal space to the right of the sternum
D. Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.
A home health nurse is visiting the home of a caregiver who says he is "exhausted" from working part-time in addition to caring for his mother, who is an older adult and has severe dementia. Which of the following options should the nurse suggest to the caregiver? Rehabilitation Assisted-living facility Respite care Adult day care facility
respite care Respite care is a service for caregivers who need free time to rest, away from multiple responsibilities related to the care of a family member who needs assistance.
A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include? "Sit with your back supported." "Keep your knees at hip level." "Use an ergonomically designed computer keyboard." "Keep your elbows away from your body."
A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic positioning of the wrists can help prevent carpal tunnel syndrome.
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? Start chest compressions Provide breaths with a manual resuscitation bag Administer oxygen Establish an airway
A. Start chest compressions The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Change the topic because the client is trying to divert attention from the illness to the nurse Encourage the client to express his thoughts about death and dying Tell the client that religious beliefs are a personal matter Offer to contact the client's minister or the facility's chaplain
B. Encourage the client to express his thoughts about death and dying The nurse should recognize the client's need to talk about impending death and should encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate.
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Contact the family and ask them to stay with the client Offer to call the client's minister Sit and hold the client's hand Leave the room and allow the client to cry privately
With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client. Sit and hold the client's hand
A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take? Smear the small amount of blood onto the testing strip Hold the finger above heart level Massage the client's fingertip Wrap the client's finger in a warm washcloth
Wrap the client's finger in a warm washcloth Correct answer: (D) Wrap the client's finger in a warm washcloth. Warmth helps increase the blood flow to the client's finger. Incorrect Answers:A. Smearing the blood on the reagent strip will cause an inaccurate result.
A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? Close the door to the client's room Evacuate the client from the room Sound the fire alarm Activate the fire extinguisher
B. Evacuate the client from the room The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. The first priority is rescue or removal of the client from immediate danger. The second action is activation of the fire alarm system. The third action is the confinement of the fire by closing doors and windows. The final action is to extinguish the fire, if possible, using an available fire extinguisher. If attempts to extinguish a fire could compromise the safety of clients or staff, the nurse should await the arrival of emergency fire personnel.
A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the surgeon? Platelet count 210,000/mm^3 WBC count 18,000/mm^3 Sodium 140 mEq/L Fasting glucose 92 mg/dL
B. WBC count 18,000/mm^3 This WBC count is above the expected reference range, indicating infection. The nurse should report this finding to the surgeon immediately, as it might result in postponement of the surgical procedure.
