The nurse is assigned to care for a client in traction. The nurse creates a plan of a care for the client and would include which action in the pian?

A) Leave the room to pull the fire alarm: While pulling the fire alarm is an important step in alerting others to the fire, it is not the nurse's priority action when a fire is discovered in the client's bathroom. The immediate concern is the safety of the client. The nurse should prioritize getting the client out of harm’s way before any other actions.

B) Remove the client from their room and relocate to a safe space: This is the most appropriate first action. The nurse’s first responsibility is to ensure the client's safety. Removing the client from the immediate danger zone, which is the room with the fire, is the priority. This action helps prevent injury or death from smoke inhalation or burns. Once the client is safe, the nurse can then proceed to alert others and address the fire as needed.

C) Douse the client with a fire extinguisher, using a back-and-forth motion: This action is inappropriate because the client should never be doused with a fire extinguisher. The fire extinguisher is intended for controlling the fire, not for use on individuals. Additionally, extinguishing a fire should not take priority over ensuring the client's immediate safety by removing them from the room.

D) Close all the doors to the client's room: Closing doors can help contain the fire and prevent it from spreading, but it is not the first priority. The immediate action should focus on removing the client from the room to a safe space. After ensuring the client's safety, the nurse can then close the doors to help contain the fire while awaiting assistance.Top of FormBottom of Form

A. Intramuscular epinephrine:
Intramuscular epinephrine is typically used in cases of anaphylactic reactions, which present with symptoms such as difficulty breathing, swelling, hives, and hypotension. Flank and lower back pain are not typical signs of an anaphylactic reaction during a blood transfusion. Instead, flank pain may suggest a hemolytic reaction, which involves the destruction of red blood cells, not an allergic or anaphylactic response. Thus, epinephrine would not be the first-line treatment for this situation.

B. Intravenous corticosteroids:
Intravenous corticosteroids are often used for inflammatory reactions, such as in cases of autoimmune diseases or severe allergic reactions. While corticosteroids might be used for certain types of transfusion reactions, they are not the primary treatment for hemolytic reactions (which could cause flank and lower back pain). The primary goal in a transfusion reaction with flank pain is to manage potential hemolysis and prevent kidney damage, which would be addressed through hydration and other supportive measures.

C. High volume IV fluids:
High-volume IV fluids are the most appropriate immediate intervention for a client who is experiencing flank and lower back pain during a blood transfusion, which are signs of a potential hemolytic reaction. Hemolysis, or the breakdown of red blood cells, can lead to kidney injury, so increasing fluid volume helps flush the kidneys, promote diuresis, and reduce the risk of kidney damage. The fluids also help to dilute any hemoglobin that is released into the bloodstream, supporting the kidneys' ability to filter it out. This is the priority intervention in this scenario.

D. PO diphenhydramine:
Oral diphenhydramine is used for allergic reactions, such as mild reactions involving itching, rashes, or hives, but it is not appropriate for managing more severe transfusion reactions, such as hemolytic reactions, that cause flank and lower back pain. Diphenhydramine would not address the underlying issue of potential hemolysis and kidney injury. Therefore, it is not the correct intervention for this situation.