28. 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 into the box on the right, placing them in the order of performance. Use all the steps) (ORDERED RESPONSE)

A. Apply a tourniquet below the venipuncture site: The tourniquet should be applied above the venipuncture site to engorge the vein and make it more visible and easier to access.
B. Choose a vein that is palpable and straight: A vein that is palpable, straight, and firm provides the best chance of successful IV insertion and reduces the risk of complications like infiltration or phlebitis.
C. Elevate the client's arm prior to insertion: Elevating the arm can actually reduce venous filling and make vein access more difficult. Instead, the arm should be in a dependent position to promote vein distention.
D. Select a site on the client's dominant arm: The non-dominant arm is generally preferred for IV insertion to minimize interference with daily activities and reduce discomfort.

A. Blood pressure: An elevated blood pressure of 148/94 mm Hg in a 30-week gestation client indicates potential preeclampsia. This requires follow-up, especially since it is accompanied by other preeclampsia symptoms such as headache and edema. Prompt assessment is essential to prevent progression to severe disease.
B. Respiratory assessment: The client’s respiratory rate is 20/min, even and non-labored, with clear breath sounds and 95% oxygen saturation. These are all within normal limits and do not indicate respiratory distress or compromise, so no immediate follow-up is necessary for this system.
C. Lower extremity assessment: 1+ dependent edema, though mild, can be an early sign of preeclampsia, especially when associated with elevated blood pressure and weight gain. This symptom requires monitoring for progression and possible systemic involvement.
D. Weight assessment: The client gained 0.68 kg (1.5 lb) in a week, which is above the normal range during the third trimester and may represent fluid retention. Coupled with hypertension and edema, it supports the suspicion of preeclampsia and warrants follow-up.
E. Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 bpm and shows no signs of distress. No immediate intervention is needed for fetal status at this time based on the tracing.
F. Nausea: Although nausea can be common in pregnancy, when it appears with headache and right upper quadrant pain, it may be part of the symptom complex for preeclampsia or HELLP syndrome. This combination should be followed up with further evaluation.
G. Fundal height: A fundal height of 29 cm at 30 weeks is within acceptable variation (±2 cm of gestational age), indicating appropriate fetal growth. This finding does not require follow-up at this time.
H. DTR: 3+ deep tendon reflexes suggest hyperreflexia, which is a neurological sign that can precede seizures in preeclampsia. When seen alongside elevated blood pressure and other systemic symptoms, it requires urgent follow-up to prevent maternal complications.