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 B
Explanation
Choice A rationale
Applying a cool pack to the heel prior to the procedure is not recommended as it can constrict blood vessels and make it more difficult to obtain a blood sample.
Choice B rationale
Puncturing the outer aspect of the heel is the correct technique for collecting a capillary blood specimen from an infant. This area has fewer nerve endings and is less likely to cause pain or injury.
Choice C rationale
Using a surgical blade to obtain the specimen is not appropriate for a capillary blood draw. A lancet should be used instead to make a small puncture in the skin.
Choice D rationale
Wiping the site with alcohol after the puncture is not recommended as it can cause irritation and discomfort. The site should be cleaned with alcohol before the puncture and then covered with a sterile gauze pad after the procedure.
Correct Answer is A
Explanation
Choice A rationale
Weighing the child once per day is crucial in the acute stage of nephrotic syndrome to monitor fluid retention and the effectiveness of treatment. Daily weight monitoring helps in assessing the child’s fluid balance and detecting any sudden weight gain, which could indicate worsening edema.
Choice B rationale
Increasing fluid intake to 2 L/day is not recommended for a child in the acute stage of nephrotic syndrome. This condition is characterized by significant protein loss leading to edema, and increasing fluid intake would exacerbate the problem. Fluid restriction is often necessary to manage edema.
Choice C rationale
Positioning the child supine at bedtime is not beneficial for managing nephrotic syndrome. Elevating the child’s head and legs can help reduce edema, while supine positioning might worsen it by allowing fluid to accumulate in dependent areas.
Choice D rationale
Limiting calorie intake to 45 cal/kg/day is not appropriate for a child with nephrotic syndrome. Adequate nutrition is essential for healing and recovery, and restricting calories could be harmful. The focus should be on providing a balanced diet to support the child’s overall health.