A nurse is caring for a client.

Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.

Notify the healthcare provider.
The nurse should first notify the healthcare provider of the error in administering the IV bolus.
This is important because the healthcare provider can assess the situation and provide guidance on how to proceed.
Choice A is not the correct answer because obtaining the client’s vital signs is important but not the first action the nurse should take.
Choice C is not the correct answer because documenting the incident in the client’s medical record is important but not the first action the nurse should take.
Choice D is not the correct answer because assessing the client for adverse reactions is important but not the first action the nurse should take.

The correct answers are:

• c."I need to have a fire escape plan with my family."
• d."I will use the grab bars when getting in and out of the bathtub."

Rationale for each choice:

Choice c:

Having a fire escape plan is crucial for home safety. It ensures that all family members know what to do in the event of a fire, which can save valuable time and lives. Here's a detailed explanation of why a fire escape plan is essential:

1. Early Escape:A plan promotes quick evacuation,as everyone understands the escape routes and procedures.
2. Reduced Panic:Knowing what to do in a crisis minimizes panic and confusion,allowing for calmer and more efficient actions.
3. Accountability:The plan ensures that no one is left behind,especially children,older adults,or individuals with disabilities.
4. Firefighter Assistance:It provides vital information to firefighters,aiding their rescue efforts.
5. Regular Practice:Regularly practicing the plan familiarizes everyone with their roles and actions,ensuring smoother execution in a real fire.

Choice d:

Grab bars provide stability and support, reducing the risk of falls in bathrooms. Falls are a major safety hazard, especially for older adults, and can lead to serious injuries. Grab bars offer several benefits, including:

1. Entering and Exiting:They facilitate safe entry and exit from the bathtub or shower,especially on slippery surfaces.
2. Balance Support:They provide support when standing,reducing the likelihood of losing balance.
3. Transfer Assistance:They assist individuals with mobility impairments in safely transferring between the bathtub,shower,or toilet.
4. Confidence Boost:They offer a sense of security,allowing individuals to feel more confident and independent in the bathroom.

Rationale for incorrect choices:

Choice a:

Setting a hot water heater to 140 degrees Fahrenheit is unsafe. It can cause scalding burns within seconds, especially for children and older adults. The recommended temperature is 120 degrees Fahrenheit to balance safety and energy efficiency.

Choice b:

Taping over frayed electrical cords is a temporary and hazardous fix. It does not address the underlying issue of damaged wiring, which can lead to electrical shocks, fires, or electrocution. Frayed cords should be replaced immediately with new, undamaged ones.