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
An increase in potassium levels is not an indicator of the effectiveness of furosemide, which is a diuretic used to reduce fluid overload.
Choice B rationale
A decrease in peripheral edema indicates that furosemide is effectively reducing fluid retention in the body.
Choice C rationale
A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart function.
Choice D rationale
An increase in venous pressure is not an indicator of the effectiveness of furosemide and may suggest fluid overload.
Correct Answer is A
Explanation
Choice A rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is designed to assess pain in children who are unable to communicate their pain verbally, including those who are cognitively impaired. It evaluates five categories: facial expression, leg movement, activity, cry, and consolability, each scored from 0 to 2, with a total score ranging from 0 to 1012.
Choice B rationale
The FACES pain scale is a self-report tool that uses facial expressions to help children aged 3 and older communicate their pain level. It is not suitable for toddlers who are cognitively impaired and unable to self-report.
Choice C rationale
The Visual Analog Scale (VAS) is a unidimensional measure of pain intensity, typically used in older children and adults who can understand and mark their pain level on a continuum. It is not appropriate for toddlers who are cognitively impaired.
Choice D rationale
The CRIES scale is used to assess pain in neonates and infants, particularly postoperatively. It evaluates crying, oxygen requirement, increased vital signs, facial expression, and sleeplessness. It is not designed for toddlers.