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 C
Explanation
Choice A rationale
Increasing fluid intake is not appropriate as it does not address the issue of vomiting and can lead to fluid overload.
Choice B rationale
Giving an antiemetic is not recommended without consulting a healthcare provider as it may interact with digoxin.
Choice C rationale
Administering the next dose as prescribed is the correct action. If a dose is vomited, it should not be repeated, and the next dose should be given at the regular time.
Choice D rationale
Mixing the medication with 8 oz of formula is not recommended as it can affect the absorption and effectiveness of the medication.
Correct Answer is B
Explanation
Choice A rationale
Applying a cool pack to the heel prior to the procedure is not recommended as it can constrict blood vessels and make it more difficult to obtain a blood sample.
Choice B rationale
Puncturing the outer aspect of the heel is the correct technique for collecting a capillary blood specimen from an infant. This area has fewer nerve endings and is less likely to cause pain or injury.
Choice C rationale
Using a surgical blade to obtain the specimen is not appropriate for a capillary blood draw. A lancet should be used instead to make a small puncture in the skin.
Choice D rationale
Wiping the site with alcohol after the puncture is not recommended as it can cause irritation and discomfort. The site should be cleaned with alcohol before the puncture and then covered with a sterile gauze pad after the procedure.