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
Koplik spots are small, bluish-white spots with a red halo that appear inside the cheeks and are a characteristic sign of measles.
Choice B rationale
Koplik spots do not appear on the tongue.
Choice C rationale
Koplik spots do not appear on the gums.
Choice D rationale
Koplik spots do not appear inside the lips.
Correct Answer is B
Explanation
Choice A rationale
Performing the dressing change independently does not demonstrate effective collaboration. Effective collaboration involves working with other healthcare professionals to provide the best care for the patient. By performing the dressing change independently, the nurse is not utilizing the expertise and support of the healthcare team.
Choice B rationale
Seeking guidance from the wound care nurse demonstrates effective collaboration. The wound care nurse has specialized knowledge and skills in wound management, and seeking their guidance ensures that the patient receives the best possible care. This collaborative approach enhances patient outcomes and promotes a team-based approach to healthcare.
Choice C rationale
Asking another nurse to complete the dressing change does not demonstrate effective collaboration. While delegating tasks can be part of collaboration, it is important that the nurse seeks guidance from the appropriate specialist, in this case, the wound care nurse, to ensure the best care for the patient.
Choice D rationale
Consulting only the client’s family for assistance does not demonstrate effective collaboration. While involving the family in the care process is important, it is essential to collaborate with other healthcare professionals who have the expertise to provide the best care for the patient.