A nurse enters a client's room and sees a small fire in the client's bathroom.

Identify the sequence of steps the nurse should take.

(Move the steps, placing them in the order of performance. Use all the steps.)

Use the unit's fire extinguisher to attempt to put out the fire.

Close all nearby windows and doors.

Activate the facility's fire alarm system.

Transport the client to another area of the nursing unit.

Answer and Explanation

The Correct Answer is D,C,B,A

In the event of a fire, the nurse should prioritize safety and follow the facility’s emergency protocols, which typically align with the “RACE” acronym: Rescue: d. Transport the client to another area of the nursing unit. Ensure the client is safe from immediate danger. Alarm: c. Activate the facility’s fire alarm system. Alert others in the facility by activating the fire alarm. Confine: b. Close all nearby windows and doors. Prevent the spread of fire by closing doors and windows. Extinguish: a. Use the unit’s fire extinguisher to attempt to put out the fire. If it’s safe to do so, attempt to extinguish the fire using a fire extinguisher. Remember, the safety of the client and the nurse is the top priority. If the fire is too large or the situation too dangerous, the nurse should evacuate and wait for the fire department to handle the situation. Always follow the specific procedures of your healthcare facility.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Requesting additional information about the caller's relationship to the client does not ensure the caller's identity is verified, and it could still result in a breach of confidentiality.

Choice B rationale: Providing a general update about the client's condition over the telephone is not appropriate, as it could breach the client's confidentiality.

Choice C rationale: Referring the family member to the client's provider for the update respects confidentiality and ensures that information is only provided to authorized individuals, maintaining the client's privacy.

Choice D rationale: Encouraging the family member to contact the client directly for information ensures that the client has control over their own information and maintains confidentiality. This action respects the client's privacy and autonomy.

A. A client who has epidural analgesia and weakness in the lower extremities. B. A client who has diabetes mellitus and an HbA1c of 6.89%. C. A client who has a hip fracture and a new onset of tachypnea. D. A client who has sinus arrhythmia and is receiving cardiac monitoring.

Correct Answer is C

Explanation

Choice A rationale:

The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.

Choice B rationale:

The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.

Choice C rationale:

The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.

Choice D rationale:

The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.

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A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps, placing them in the order of performance. Use all the steps.)

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A nurse enters a client's room and sees a small fire in the client's bathroom.

Identify the sequence of steps the nurse should take.

(Move the steps, placing them in the order of performance. Use all the steps.)