while making rounds at 3am the nurse discovers a small fire in a clients room what should the nurse do first
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Nursing Elites

NCLEX-PN

NCLEX Question of The Day

1. While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?

Correct answer: A

Rationale: During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.

2. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

3. What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?

Correct answer: B

Rationale: The correct answer is 'homeostasis.' These ABG values fall within the normal range, indicating a state of balance and homeostasis. The pH is within the normal range (7.35-7.45), the PCO2 is normal (35-45 mmHg), and the HCO3 level is also normal (22-26 mEq/L). Choice A, 'metabolic alkalosis,' is incorrect because the pH, PCO2, and HCO3 levels are not indicative of metabolic alkalosis. Choice C, 'respiratory acidosis,' is incorrect as the pH and PCO2 values are not elevated. Choice D, 'respiratory alkalosis,' is incorrect as the pH and PCO2 levels are not decreased. Therefore, the ABG values provided do not correspond to any acid-base disturbance, confirming that the patient is in a state of homeostasis.

4. Which client is at risk for hypomagnesemia?

Correct answer: D

Rationale: The correct answer is the client admitted with alcohol abuse. Alcoholics tend to have poor nutrition due to decreased food intake, which is a common source of magnesium. Additionally, alcohol suppresses the release of ADH, leading to diuresis and magnesium loss. Choice A is incorrect because a history of heart disease does not directly increase the risk of hypomagnesemia. Choice B is incorrect as taking magnesium-based antacids would not put the client at risk for hypomagnesemia; in fact, it would help prevent it. Choice C is also incorrect as a parathyroid disorder is not typically associated with an increased risk of hypomagnesemia.

5. What must the evening nurse do to facilitate the client's ECT treatment the next morning?

Correct answer: A

Rationale: For electroconvulsive therapy (ECT) treatment, obtaining informed consent is crucial before the procedure. This ensures the patient is aware of the risks, benefits, and alternatives to the treatment. Administering medications, ensuring rest, and dietary restrictions are important but not directly related to the specific requirement of obtaining informed consent for ECT. The correct answer, ensuring the patient signs an informed consent form, is essential to uphold the patient's autonomy and ensure they have the necessary information to make an informed decision about their treatment.

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