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
Engaging in parallel play is a normal developmental behavior for an 18-month-old toddler. It indicates that the child is beginning to interact with peers, even if they are not yet playing cooperatively.
Choice B rationale
Walking with assistance at 18 months may indicate a potential developmental delay. By this age, most toddlers should be able to walk independently. If a child is still requiring assistance, it may warrant further evaluation.
Choice C rationale
Speaking at least 10 words is within the expected developmental range for an 18-month-old. This milestone indicates that the child is developing language skills appropriately.
Choice D rationale
Building a tower of 3 blocks is a typical developmental milestone for an 18-month-old. It demonstrates fine motor skills and cognitive development.
Correct Answer is C
Explanation
Choice A rationale
Repeating childhood immunizations once in remission is not necessary. Children with HIV should follow the standard immunization schedule with some modifications based on their immune status.
Choice B rationale
The risk of transmission does not significantly decrease after just 2 weeks on zidovudine. Continuous adherence to antiretroviral therapy is essential for reducing viral load and transmission risk.
Choice C rationale
Ensuring the child is tested for tuberculosis every year is important. Children with HIV are at higher risk for TB due to their compromised immune systems.
Choice D rationale
Doubling medications for 6 months is not a standard practice and can lead to toxicity and adverse effects. Medication dosages should be carefully managed by healthcare providers.