To accurately take a client's blood pressure, which action by the nurse is most important?

The correct answer is choice C: Move any clients to safety.

Choice C rationale: The nurse's priority is always client safety. In the event of an electrical issue that poses a potential risk, such as smoke or fire, the nurse should first ensure that any clients in the area are moved to a safe location. This aligns with the widely-used RACE acronym for fire response (Rescue, Alarm, Confine, Extinguish), which highlights the importance of removing individuals from danger before attending to other aspects of fire safety.

Choice A rationale: Using a fire extinguisher is an appropriate action to take when dealing with a small, manageable fire. However, in this scenario, ensuring client safety takes precedence over attempting to extinguish the source of the smoke. This is also in line with the RACE mnemonic, which emphasizes the importance of prioritizing evacuation.

Choice B rationale: Activating the fire alarm is an important step to alert others in the building about a potential fire and the need for evacuation. However, the priority remains client safety, so moving clients to a safe location should be the nurse's initial response, following the RACE acronym.

In summary, the nurse's priority action when encountering an electrical hazard is to move clients to safety. After ensuring client safety, the nurse can then activate the fire alarm and, if trained to do so, use a fire extinguisher on the outlet if necessary. This approach aligns with the RACE mnemonic, which serves as a guideline for fire response.

Choice A rationale:

Providing the AP with the appropriate PPE (Choice A) is a good immediate action, but it does not address the issue comprehensively. It is crucial to report the incident to the higher authorities to ensure that appropriate measures are taken to prevent similar occurrences in the future.

Choice B rationale:

Notifying the charge nurse about the AP's lack of PPE (Choice B) is the most appropriate action in this situation. The charge nurse is responsible for overseeing the staff and ensuring compliance with safety protocols. Reporting the incident to the charge nurse allows for appropriate disciplinary action, additional training, or reminders about infection control procedures to prevent future violations.

Choice C rationale:

Volunteering to provide an in-service about infection control (Choice C) is a positive initiative, but it might not address the immediate issue at hand. While education is essential, the pressing matter is the AP's violation of infection control protocols, which needs to be reported promptly to the charge nurse.

Choice D rationale:

Speaking with the AP before leaving the shift about the appropriate protocol (Choice D) is insufficient on its own. While educating the AP about the correct protocols is essential, it should not replace reporting the incident to the charge nurse. Reporting ensures that appropriate actions are taken to maintain a safe environment for both healthcare workers and patients.