The nurse is extinguishing a fire that has broken out in the workplace.
Which is the first step the nurse should take?

Choice A rationale:

Confine the fire by closing doors and windows. While confining the fire is important, the nurse's first priority should be ensuring the safety of the client. Closing doors and windows may help prevent the fire from spreading, but it does not address the immediate danger to the client.

Choice B rationale:

Activate the fire alarm system. Activating the fire alarm is a crucial step to alert other staff members, patients, and visitors about the fire. However, it is not the first action the nurse should take. Ensuring the safety of the client should be the top priority.

Choice C rationale:

Extinguish the fire if possible. Attempting to extinguish the fire can be dangerous for the nurse and may waste precious time. The nurse's safety and the client's safety should be the primary concern. Trying to put out the fire before ensuring the client's safety is not the best course of action.

Choice D rationale:

Rescue the client from immediate danger. This is the correct answer because the nurse's first priority in a fire emergency is to ensure the safety of the client. Rescuing the client from immediate danger should be done before any other actions are taken. The nurse should assess the situation, help the client to safety, and then notify others about the fire and activate the alarm system.

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.