A nurse is planning care for a client who is immobile. Which of the following actions should the nurse include in the plan of care?

A. Direct a fire extinguisher at the fire:

While using a fire extinguisher is an essential action in controlling a small fire, it should come after the fire alarm has been activated. Alerting others to the fire and initiating the emergency response system take precedence to ensure a coordinated and safe response.

B. Place wet towels along the base of the door:

Placing wet towels along the base of the door is a method to help prevent smoke from entering the room. However, in this situation, after ensuring the client's safety, the nurse should focus on activating the facility's fire alarm to alert others and initiate the emergency response.

C. Turn off any electrical equipment:

While turning off electrical equipment is a generally sound practice in fire safety, it is not the immediate next action after moving the client to safety. Activating the fire alarm takes precedence as it initiates a coordinated response and alerts others to the emergency.

D. Activate the facility's fire alarm:

This is the correct action. Activating the fire alarm is a critical step in alerting the entire facility to the presence of a fire. It ensures that emergency response teams are notified promptly, and appropriate measures can be taken to address the fire, including evacuating other occupants and summoning professional firefighting assistance.

A. Use trochanter rolls beside the client's legs:

Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.

B. Logroll the client every 4 hr:

Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.

C. Place the client's arms at their side when turning them:

Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.

D. Cross the client's ankles when lying supine:

Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.