A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

Assign clients to the remaining staff.

Call the supervisor to ask for another nurse.

Remove the nurse from the client care area.

Document objective findings about the situation.

Answer and Explanation

The Correct Answer is C

A. Assign clients to the remaining staff is not the first action. The nurse should address the suspected impairment of the staff member before assigning clients to others.

B. Call the supervisor to ask for another nurse is not the first action. While notifying the supervisor is important, the nurse should first ensure that the impaired nurse is removed from direct client care to prevent any potential harm to clients.

C. Remove the nurse from the client care area is correct. The first priority is to ensure that the nurse who may be impaired is not caring for clients to ensure client safety.

D. Document objective findings about the situation is important but not the first step. The immediate priority is ensuring the safety of clients by removing the nurse from the care area. Documentation can follow after ensuring client safety.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Wipe any excess medication from the inner canthus outward: This is the correct approach. When administering ophthalmic ointment, the nurse should wipe away any excess from the inner canthus to the outer canthus to prevent contamination of the unaffected eye and to avoid spreading the infection.

B. Instruct guardian to apply erythromycin ophthalmic ointment every morning for 14 days.: This is incorrect because the child has been prescribed bacitracin ophthalmic ointment, not erythromycin. The nurse should instruct the guardian to use the prescribed medication as directed.

C. Gently massage the eyelid to facilitate absorption of the medication.: Massaging the eyelid is unnecessary and could lead to irritation or injury. The medication should be allowed to be absorbed naturally without additional manipulation.

D. Place an occlusive dressing on the affected eye to prevent the spread of infection.: An occlusive dressing is not recommended as it may cause increased irritation or pressure on the eye. The best practice is to maintain proper hygiene and follow the prescribed medication regimen.

A. Productive cough with pink, frothy sputum B. Weight loss of 1 kg (2.2 lB. in the past 24 hr C. Fatigue when ambulating 152 m (500 ft)

Correct Answer is A

Explanation

A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.

B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.

C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.

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A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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