A nurse is reinforcing teaching about disease management with client who has GERD. Which of the following statements should the nurse make?

Correct answers: C

Rationale:

A. Staff members using a class A fire extinguisher for an electrical fire is incorrect and dangerous. Class A extinguishers are for ordinary combustibles like paper and wood. Electrical fires require class C extinguishers to prevent the conduction of electricity.

B. Reviewing the locations of fire extinguishers every 2 to 3 years is insufficient for an effective safety plan. Regular fire safety drills and location reviews should occur at least annually. Frequent reinforcement ensures rapid response during a real fire emergency.

C. An evacuation order when fire extinguishers are ineffective indicates an effective safety plan and sound clinical judgment. The priority in the RACE acronym is to rescue and then evacuate if the fire is not contained. This protects life when suppression fails.

D. Fire alarms having the same sound as other alarms is a failure in safety design. Distinctive auditory signals are required to prevent confusion during an emergency. Unique alarms ensure that staff and patients immediately identify the specific nature of the threat.

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.