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
Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority. Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss.
Choice B rationale
Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss. This action helps to stop the bleeding and stabilize the patient.
Choice C rationale
Obtaining vital signs is important, but it can wait momentarily until the bleeding is under control. The immediate priority is to stop the bleeding.
Choice D rationale
Monitoring the pulse distal to the insertion site is important, but controlling bleeding takes precedence. Once the bleeding is controlled, the nurse can then monitor the pulse
Correct Answer is C
Explanation
Choice A rationale
Checking the newborn’s eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy. The primary concern during phototherapy is monitoring the newborn’s temperature and hydration status.
Choice B rationale
Placing mittens on the newborn’s hands is unrelated to the management of hyperbilirubinemia or phototherapy. Mittens are typically used to prevent the newborn from scratching themselves.
Choice C rationale
Monitoring the newborn’s temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights. This helps ensure the newborn maintains a stable body temperature.
Choice D rationale
Applying lotion to the newborn’s skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights. The lotion can act as a barrier, reducing the amount of light that reaches the skin.