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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Assign the task to another AP" is not the best first response. The nurse should first understand why the AP is refusing the task and address any concerns before reassigning the task.
B. "Report the AP to the risk manager" is premature. The nurse should first attempt to understand the AP’s reasons for refusal and resolve any concerns directly. Reporting should only occur if the issue persists and cannot be resolved.
C. "Discuss the AP's concerns about performing the task" is correct. The nurse should open a dialogue with the AP to understand why they are refusing the task. This allows the nurse to assess if the refusal is due to lack of knowledge, skill, or comfort, and then provide the necessary support, guidance, or training.
D. "Perform the task on behalf of the AP" is not ideal. The nurse should not assume the task but rather address the issue with the AP. The nurse should only intervene if the task needs to be completed urgently, but the first step should be to explore the reasons for refusal.
Correct Answer is A
Explanation
A. Injecting 15 units of air into the regular insulin vial is correct. When drawing up two types of insulin, the nurse should first inject air into the NPH (cloudy) insulin vial without withdrawing the medication. Then, the nurse should inject air into the regular (clear) insulin vial before withdrawing the regular insulin. This prevents contamination and maintains proper insulin mixing procedures.
B. Placing the cap over the needle is incorrect. Once insulin preparation has started, recapping the needle is unnecessary and increases the risk of contamination or needlestick injury.
C. Verifying the dosage with another nurse is incorrect at this stage. Dosage verification should be done after the correct amounts of insulin are drawn into the syringe, not before.
D. Withdrawing 10 units of NPH insulin is incorrect. The nurse should first withdraw the regular (clear) insulin before drawing up the NPH (cloudy) insulin to avoid contaminating the regular insulin with the longer-acting insulin.
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