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
Assisting the adolescent to ambulate 12 hours following surgery is not recommended. Early ambulation is important, but 12 hours post-surgery is too soon and can lead to complications such as increased pain and risk of injury.
Choice B rationale
Ensuring two nurses logroll the adolescent every 2 hours is crucial. Logrolling helps maintain spinal alignment and prevents complications such as pressure ulcers and respiratory issues.
Choice C rationale
Maintaining the head of the bed at a 30° angle is not appropriate immediately post-surgery as it can increase pressure on the surgical site and compromise spinal alignment.
Choice D rationale
Offering sips of water 4 hours following surgery is not recommended. Postoperative patients are usually kept NPO (nothing by mouth) for a certain period to prevent aspiration and other complications.
Correct Answer is B
Explanation
Choice A rationale
Holding the child during assessments may cause distress and is not recommended for children with autism spectrum disorder.
Choice B rationale
Establishing a reward system is an effective intervention for children with autism spectrum disorder as it reinforces positive behaviors.
Choice C rationale
Maintaining extended eye contact can be uncomfortable for children with autism and is not recommended.
Choice D rationale
Engaging in cooperative play may be challenging for children with autism, and structured activities are often more beneficial.