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
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Obtaining a throat culture is not recommended for a child with epiglottitis due to Haemophilus influenzae type B because it can cause further airway obstruction and distress.
Choice B rationale
Inspecting the epiglottis is not advisable as it can cause further airway obstruction and distress. Visualization of the epiglottis should be done in a controlled environment, such as an operating room, by a specialist.
Choice C rationale
Beginning droplet precautions is essential for preventing the spread of Haemophilus influenzae type B, which is transmitted through respiratory droplets.
Choice D rationale
Monitoring oxygen saturation is crucial for assessing the child’s respiratory status and ensuring adequate oxygenation.
Choice E rationale
Initiating IV access is necessary for administering medications and fluids to manage the child’s condition effectively.