A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first?

Assist clients who are in immediate danger to a safe location.

Close doors and windows on the unit.

Attempt to extinguish the fire using an ABC fire extinguisher.

Discontinue oxygen use for clients who can breathe without it.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse's first priority in the event of a fire is the safety and well-being of the clients. Clients who are in immediate danger due to the fire should be assisted to a safe location as quickly as possible. This choice is supported by the principles of prioritizing client safety during emergencies.

Choice B rationale:

Closing doors and windows on the unit is a secondary action and comes after ensuring the safety of clients in immediate danger. While it can help contain the fire's spread, it should not be the nurse's first action, as it does not address the immediate risk to clients' lives.

Choice C rationale:

Attempting to extinguish the fire using an ABC fire extinguisher might be a consideration in emergency situations; however, the nurse's first responsibility is to ensure the safety of clients. The nurse should not put themselves or clients at risk by attempting to extinguish the fire before moving clients to safety.

Choice D rationale:

Discontinuing oxygen use for clients who can breathe without it is not the nurse's primary action during a fire emergency. While it's important to manage resources, such as oxygen, the immediate focus should be on evacuating clients from the danger zone.

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Correct Answer is C

Explanation

Choice A rationale:

Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.

Choice B rationale:

A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.

Choice C rationale:

Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.

Choice D rationale:

A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.

A. Open the top flap of the sterile package towards the body. B. Maintain a 1.25 cm (0.5 in) border around the edges of the sterile field. C. Pick up the first sterile glove by grasping the folded cuff edge. D. Remove soiled dressings using sterile gloves.

Correct Answer is C

Explanation

The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.

Choice A rationale:

Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.

Choice B rationale:

Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.

Choice C rationale:

Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.

Choice D rationale:

Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.

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A nurse receives notification of a fire on the unit. Which of the following actions should the nurse take first?

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