A practical nurse (PN) enters a client's room and observes the client attempting to light a cigarette while receiving continuous oxygen therapy via a nasal cannula. In what order should the PN perform the following actions? (Arrange the actions in the correct sequence, from first to last.)
- 1Turn off the oxygen flowmeter and confiscate the lighter and cigarette.
- 2Obtain the client's current oxygen saturation and respiratory rate.
- 3Notify the charge nurse of the safety incident and interrupted oxygen therapy.
- 4Reinforce facility policies and the extreme fire hazard of smoking near oxygen.
- 5Document the behavioral incident, the client's status, and the education provided.
Answer
The correct sequence of actions is: 1) Turn off the oxygen and confiscate the smoking materials, 2) Obtain vital signs and oxygen saturation, 3) Notify the charge nurse, 4) Reinforce teaching regarding fire hazards, and 5) Document the incident.
In any clinical scenario involving high-risk behavior that poses an immediate threat to life, the absolute first priority is risk reduction and safety. Because oxygen supports combustion, smoking in its presence is a catastrophic fire hazard; thus, stopping the oxygen and removing the cigarette is the priority. Second, because therapy was interrupted, the PN must assess the client's respiratory status. Third, the PN must report this critical event to the charge nurse so the interdisciplinary team can manage the client's care. Fourth, the PN reinforces education to prevent a recurrence. Finally, the PN documents the entire event chronologically.
Step-by-Step Solution
Key Concept
Prioritization of safety and risk reduction during acute high-risk behavioral incidents.