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
Bradypnea, or slow breathing, is a common and serious side effect of morphine, especially in children. It requires immediate attention.
Choice B rationale
Morphine does not typically affect wound healing. This is more associated with corticosteroids.
Choice C rationale
Morphine can cause hypotension, not hypertension.
Choice D rationale
Stevens-Johnson syndrome is a rare but severe reaction to medications, including some antibiotics and anticonvulsants, but not commonly associated with morphine.
Correct Answer is C
Explanation
Choice A rationale
Enuresis (bedwetting) is not an immediate concern in a child with sickle cell anemia and does not require urgent reporting to the provider.
Choice B rationale
Kyphosis (curvature of the spine) is not an immediate concern in a child with sickle cell anemia and does not require urgent reporting to the provider.
Choice C rationale
Facial twitching is a priority finding as it may indicate a neurological complication or electrolyte imbalance, which requires immediate attention and intervention.
Choice D rationale
Constipation is not an immediate concern in a child with sickle cell anemia and does not require urgent reporting to the provider.