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 A
Explanation
Choice A rationale
Keeping electrical wires hidden from view is essential to prevent toddlers from pulling on them, which can lead to electrical burns or other injuries. It is a proactive measure to ensure a safe environment for children who are naturally curious and prone to exploring with their hands.
Choice B rationale
Encouraging outdoor activities between the hours of 1100 and 1300 can expose toddlers to the sun’s peak intensity, increasing the risk of sunburn. It is safer to encourage outdoor activities outside these hours when the sun is less intense.
Choice C rationale
Setting the water heater to 60°C (140°F) is too high and poses a scalding risk. The recommended temperature to prevent burns is 49°C (120°F), which is hot enough for household use but not so hot as to cause immediate burns upon contact.
Choice D rationale
Turning pot handles toward the front of the stove is dangerous as it increases the risk of toddlers reaching up and pulling hot contents onto themselves. The correct practice is to turn pot handles toward the back of the stove to keep them out of reach of children.
Correct Answer is C
Explanation
Choice A rationale
A hemoglobin level of 6.8 g/dL is significantly lower than the normal range (9.5 to 14 g/dL) and indicates anemia. This finding does not suggest that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice B rationale
An RBC count of 5/mm³ is within the normal range (4 to 5.5/mm³) but does not specifically indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.
Choice C rationale
A WBC count of 15,000/mm³ is higher than the normal range (5,000 to 10,000/mm³) but can indicate that the treatment is having a therapeutic effect. In the context of acute lymphoblastic leukemia, an elevated WBC count can be a sign that the body is responding to treatment.
Choice D rationale
A platelet count of 98,000/mm³ is lower than the normal range (150,000 to 400,000/mm³) and does not indicate that the treatment for acute lymphoblastic leukemia is having a therapeutic effect.