A nurse is working in a nursing home. What is the first priority for the nurse in this situation?
Ensure that all patients are moved out of harm’s way.
Remove all flammable materials from the area and extinguish the fire.
Report to the area of the fire and take measures to extinguish and/or contain it, if possible.
Evacuate all patients from the building immediately.
The Correct Answer is A
Choice A rationale
Ensuring that all patients are moved out of harm’s way is the first priority in a nursing home fire situation. This action aligns with the principles of the ABCs of nursing prioritization, where ensuring safety and preventing harm is paramount.
Choice B rationale
Removing all flammable materials from the area and extinguishing the fire is important, but it comes after ensuring the safety of the patients. The primary focus should be on patient safety.
Choice C rationale
Reporting to the area of the fire and taking measures to extinguish and/or contain it, if possible, is a secondary action. The immediate priority is to ensure the safety of the patients.
Choice D rationale
Evacuating all patients from the building immediately is not always feasible or safe. The priority is to move patients out of immediate harm’s way and then proceed with further evacuation if necessary.
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Correct Answer is C
Explanation
Choice A rationale
Administering vaccines prior to discharge is not recommended for a child with neutropenia because their immune system is compromised. Vaccines, especially live vaccines, can pose a risk of infection in immunocompromised individuals.
Choice B rationale
Obtaining the child’s rectal temperature once daily is not advisable for a child with neutropenia. Rectal thermometers can cause mucosal injury and increase the risk of infection in neutropenic patients.
Choice C rationale
Avoiding raw fruits and vegetables in the child’s diet is crucial for a child with neutropenia. Raw fruits and vegetables can harbor bacteria and other pathogens that can cause infections in immunocompromised individuals.
Choice D rationale
Bathing the child every other day is not sufficient for maintaining hygiene in a child with neutropenia. Daily bathing is recommended to reduce the risk of infection by removing potential pathogens from the skin.
Correct Answer is D
Explanation
Choice A rationale
Rotavirus vaccination is typically administered in infancy, not at 5 years of age. The rotavirus vaccine is given to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration in young children. By the age of 5, children have usually completed the rotavirus vaccination series.
Choice B rationale
Hepatitis B vaccination is also typically completed in infancy. The hepatitis B vaccine is given to infants to protect against hepatitis B virus infection, which can cause chronic liver disease and liver cancer. By the age of 5, children who are up-to-date with their immunizations have usually completed the hepatitis B vaccination series.
Choice C rationale
Haemophilus influenzae type b (Hib) vaccination is typically completed by 15 months of age. The Hib vaccine protects against infections caused by Haemophilus influenzae type b, such as meningitis, pneumonia, and epiglottitis. By the age of 5, children who are up-to-date with their immunizations have usually completed the Hib vaccination series.
Choice D rationale
The second dose of the varicella vaccine is usually given at 4-6 years of age. The varicella vaccine protects against chickenpox, a highly contagious viral infection that causes an itchy rash and fever. Administering the second dose of the varicella vaccine at this age helps ensure that the child has adequate immunity against chickenpox.