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 D
Explanation
Choice A rationale
Rinsing the child’s mouth with chlorhexidine mouthwash if they develop stomatitis is not recommended. Chlorhexidine can be harsh and may cause further irritation in a child with stomatitis.
Choice B rationale
Ensuring the administration of an antiemetic for 12 hours after chemotherapy is not sufficient. Antiemetics should be given before, during, and after chemotherapy to effectively manage nausea and vomiting.
Choice C rationale
Encouraging eating by providing the child with their favorite foods is not always appropriate. Some foods may exacerbate nausea or be contraindicated during chemotherapy.
Choice D rationale
Using a soft-bristled toothbrush when platelet levels are low is correct. This helps prevent gum bleeding and injury, which is important for children with low platelet counts due to chemotherapy.
Correct Answer is D
Explanation
Choice A rationale
Increased capillary refill time is not typically associated with hypoglycemia. It may indicate poor peripheral circulation but is not a common sign of low blood sugar levels.
Choice B rationale
Decreased appetite is not typically associated with hypoglycemia. Hypoglycemia usually causes symptoms such as shakiness, sweating, and confusion.
Choice C rationale
Thirst is not typically associated with hypoglycemia. It is more commonly a symptom of hyperglycemia (high blood sugar levels).
Choice D rationale
Shakiness or tremors are common signs of hypoglycemia. When blood sugar levels drop, the body responds by releasing adrenaline, which can cause shakiness.