A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

Attempt to extinguish the fire before evacuating clients.

Aim the spray of the fire extinguisher at the top of the fire.

Open nearby doors and windows when the fire alarm sounds.

Have ambulatory clients walk independently to a safe location

Answer and Explanation

The Correct Answer is D

Rationale:

A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.

B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.

C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.

D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.

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Correct Answer is ["A","B","C","G","H"]

Explanation

Rationale:
• Urinary stasis: Immobility slows bladder emptying and ureteral flow, increasing residual urine. This promotes bacterial growth and risk of urinary tract infection. MS clients with decreased mobility are especially vulnerable.

• Calcium resorption: Bone demineralization occurs during prolonged immobility. Without weight-bearing, calcium is released from bone into the bloodstream, raising serum calcium and weakening bones.

• Contractures: Lack of movement leads to shortening and stiffening of muscles and joints. Over time, joints lose flexibility, especially if the client remains curled in one position.

• Hypocalcemia: The client is more likely to develop hypercalcemia due to calcium resorption from bones. There's no evidence of low calcium symptoms like tetany or numbness.

• Hypertension: The client's vital signs are within normal range. Immobility may reduce cardiac output over time, but it does not typically cause high blood pressure.

• Diarrhea: Immobility usually causes constipation due to slowed peristalsis. There's no report of active GI symptoms or triggers for diarrhea in this case.

• Pressure ulcer: Continuous pressure on one area reduces capillary blood flow. This leads to tissue ischemia and skin breakdown, especially over bony prominences like the hip and shoulder.

• Atelectasis: Lying on one side restricts lung expansion, and refusal to change positions impairs ventilation. This can cause alveolar collapse and decreased oxygen exchange.

A. The restraint tie strap is tied into a knot. B. The restraint is attached to the side rails of the bed. C. The skin under the restraint is cool and has changed color. D. The nurse can insert two fingers under the restraint.

Correct Answer is D

Explanation

Rationale:

A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.

B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.

C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.

D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.

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A nurse is reinforcing teaching about the facility's fire intervention plan with new assistive personnel. Which of the following instructions the nurse include in the teaching?

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