A nurse is caring for a client who had an open cholecystectomy 24 hours ago.

The client’s vital signs have been stable over the last 24 hours, with the most recent temperature

98.6° F(37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and pulse 78/min, but are now changing.

Which set of vital signs indicates that the nurse should contact the health care provider?

This is the priority action because it follows the RACE acronym for fire safety: Rescue, Alarm, Contain, Extinguish. The nurse should first rescue the client from immediate danger by smothering the flames with a blanket.

This will also help contain the fire and prevent it from spreading.

Choice A is wrong because closing the window and removing the client’s oxygen will not put out the fire.

Oxygen is not flammable, but it can make a fire burn faster and hotter. Removing the oxygen source may help reduce the intensity of the fire, but it will not extinguish it.

Choice B is wrong because sounding the fire alarm and activating the emergency response system are important steps, but they are not the priority. The nurse should first ensure the client’s safety before alerting others and calling for help.

Choice D is wrong because removing the client from the room and closing the door may expose the client to more harm and make the fire worse.

The nurse should not move the client unless it is absolutely necessary, as this may cause further injury or infection. Closing the door may create a backdraft, which is a sudden explosion of fire caused by oxygen rushing into an enclosed space.

The directive takes effect only if the client is incapable of personally making health care decisions. This statement demonstrates an understanding of health care proxy and care because it reflects the definition of a health care proxy as a person who can make health care decisions for the client only when the client is unable to communicate these themselves.

Choice A is wrong because the daughter does not have the authority to make all of the client’s health care decisions, only those that the client has not specified in advance or that are not covered by the living will.

Choice B is wrong because no extraordinary means, such as cardiopulmonary resuscitation, will be initiated only if the client has expressed this preference in a living will or a do-not-resuscitate order.

Choice D is wrong because the closest relative, such as the spouse, does not have to be consulted before the daughter in making health care decisions, unless the client has designated them as an alternate proxy.