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
This statement is nontherapeutic because it shifts the focus away from the patient and onto the nurse’s personal experience. It can minimize the patient’s feelings and is not helpful in providing support.
Choice B rationale
Asking the patient to demonstrate how they give themselves insulin is a therapeutic communication technique. It shows interest in the patient’s self-care practices and provides an opportunity for the nurse to offer guidance and support.
Choice C rationale
This statement is nontherapeutic because it offers false reassurance. It does not address the patient’s concerns or provide any real support.
Choice D rationale
This statement is also nontherapeutic because it offers false reassurance and does not address the patient’s specific concerns or needs.
Correct Answer is D
Explanation
Choice A rationale
While explaining the procedure to the adolescent and their guardian is important, it is not the nurse’s primary responsibility to provide detailed explanations of the procedure. This should be done by the provider performing the procedure.
Choice B rationale
Witnessing the adolescent’s signature on the informed consent form is part of the nurse’s role, but it does not address the guardian’s lack of understanding about the procedure.
Choice C rationale
Requesting assistance from the anesthesiologist to clarify the misunderstanding is not appropriate, as the anesthesiologist may not be the best person to explain the procedure. The provider performing the procedure should be the one to provide clarification.
Choice D rationale
Notifying the provider who is scheduled to perform the procedure is the correct action. The provider is responsible for ensuring that the patient and their guardian fully understand the procedure and its risks and benefits before obtaining informed consent.