When using standard precautions, the nurse knows that standard precautions mandate what?

Choice A rationale:

Confine the fire by closing doors and windows. Rationale: While confining the fire is essential, the nurse's first priority should be the safety of the client. Closing doors and windows can wait. The nurse should focus on immediate actions to ensure the client's safety.

Choice B rationale:

Activate the fire alarm system. Rationale: Activating the fire alarm system is crucial to alert others in the healthcare facility about the fire. This action ensures a timely response from the fire department and other staff members, enhancing overall safety within the facility.

Choice C rationale:

Extinguish the fire if possible. Rationale: Attempting to extinguish the fire might lead to delay, especially if the nurse is not trained to handle fires properly. Moreover, the nurse's safety is paramount, and attempting to put out the fire could put the nurse at risk. Prioritizing the client's immediate rescue is the best course of action.

Choice D rationale:

Rescue the client from immediate danger. Rationale: The correct action for the nurse to take first is to rescue the client from immediate danger. This may involve helping the client out of the room or moving them away from the source of the fire. Ensuring the client's safety is the top priority, and all other actions should follow after this.

Choice A rationale:

This option is incorrect. Counting a regular pulse for 30 seconds and doubling the number is an appropriate method for assessing heart rate, not peripheral pulses. When assessing peripheral pulses, it is important to count the pulses directly for a full minute to accurately determine the pulse rate. This ensures that any irregularities or variations in the pulse rate are captured.

Choice B rationale:

This option is incorrect. Palpating the femoral artery in the groin is a standard method for assessing peripheral pulses. It is not a safety issue when performed correctly. However, the question asks about a safety issue related to assessing peripheral pulses.

Choice C rationale:

Palpating both carotid pulses at the same time is a safety issue when assessing peripheral pulses. Simultaneously palpating both carotid pulses can lead to excessive pressure on the carotid sinuses, which are baroreceptors located in the carotid arteries. Stimulation of these baroreceptors can result in a reflex decrease in heart rate and blood pressure, leading to a condition known as carotid sinus hypersensitivity. This can cause dizziness, fainting, or, in extreme cases, cardiac arrest. Therefore, it is essential to avoid palpating both carotid pulses simultaneously to prevent adverse reactions in clients, especially those with cardiovascular issues.

Choice D rationale:

Palpating the radial artery on the thumb side of the wrist is a standard method for assessing peripheral pulses. It is a safe and commonly used technique for evaluating radial pulse rate, rhythm, and amplitude. .