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 D
Explanation
Choice A rationale
Disposable diapers are not typically sources of healthcare-associated infections if used appropriately. They are designed for single use and are disposed of after use, minimizing the risk of infection.
Choice B rationale
Protective plastic gowns are not typically sources of healthcare-associated infections if used appropriately. They are designed to protect healthcare workers and patients from the spread of infections and are disposed of after use.
Choice C rationale
Unopened bottles of formula are not typically sources of healthcare-associated infections. They are sealed and sterile until opened, reducing the risk of contamination.
Choice D rationale
Bedside computer keyboards can harbor pathogens and serve as fomites for transmitting infections. They are frequently touched by healthcare workers and can become contaminated with pathogens, making them a common source of healthcare-associated infections.
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.