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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.)

Transport the client to another area of the nursing unit.

Activate the facility's fire alarm system.

Close all nearby windows and doors.

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

Answer and Explanation

The Correct Answer is A,B,C,D

The correct sequence follows the RACE protocol for fire safety:

A. Transport the client to another area of the nursing unit (R: Rescue). Rescue anyone in immediate danger.

B. Activate the facility's fire alarm system (A: Alarm). Activate the alarm system.

C. Close all nearby windows and doors (C: Contain). Contain the fire by closing doors and windows.

D. Use the unit's fire extinguisher to attempt to put out the fire (E: Extinguish). Extinguish the fire if it is safe to do so.

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Correct Answer is D

Explanation

A. Ensure that the transfusion is completed within 6 hr: Incorrect. Blood transfusions should be completed within 4 hours to reduce the risk of bacterial contamination.

B. Obtain venous access using a 22-gauge needle: Incorrect. A larger gauge (18-20) is preferred to prevent hemolysis and allow for faster administration.

C. Store the unit of blood at room temperature for 1 hr prior to the infusion: Incorrect. Blood should remain refrigerated until it is ready to be transfused, and it should be started within 30 minutes of removal from refrigeration.

D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing: 0.9% sodium chloride is the only compatible solution with blood products to prevent hemolysis.

A. Wear a face shield prior to entering the client's room. B. Place a mask on the client prior to transport. C. Use an alcohol-based hand rub following client care. D. Remove the protective gown while in the client's room.

Correct Answer is D

Explanation

A. A face shield is unnecessary unless there is a risk of splashing.

B. Masks are not needed for C. difficile, as it is not spread through airborne transmission.

C. Alcohol-based hand rubs are ineffective against C. difficile spores; handwashing with soap and water is required.

D. Contact precautions for C. difficile require the nurse to remove the protective gown and gloves inside the client's room to prevent contamination of outside areas.

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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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