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 B
Explanation
A. "Our child has a better grasp of reality.": This is not the primary goal of methylphenidate. While it may help with focus and attention, the medication's goal is to improve concentration and reduce hyperactive behaviors in children with ADHD, not directly influence their grasp of reality.
B. "Our child is able to complete his homework on time.": This is correct. Methylphenidate, a stimulant used to treat ADHD, helps improve attention, focus, and impulse control. A child who can complete homework on time demonstrates improved attention and task completion, which is the desired outcome.
C. "Our child has lost some weight since his last appointment.": While weight loss can be a side effect of methylphenidate, it is not an indicator that the medication is effective. The goal is to manage ADHD symptoms, not necessarily to cause weight loss.
D. "Our child has increased his daily caloric intake.": This is incorrect. A common side effect of methylphenidate is decreased appetite, so an increase in caloric intake would not be expected.
Correct Answer is C
Explanation
A. Inspect the preschooler's tonsils for edema.: While tonsil inspection might be part of a general assessment, in a child with suspected epiglottitis, inspecting the throat should be avoided as it can trigger airway obstruction or cause further distress.
B. Collect a sputum sample.: Sputum collection is not typically indicated for epiglottitis diagnosis. A rapid diagnosis is essential to ensure timely intervention, and sputum samples are not a key diagnostic tool for this condition.
C. Determine the preschooler's oxygen saturation level.: Epiglottitis can lead to significant airway obstruction, so monitoring the oxygen saturation level is critical to assess for hypoxia and ensure adequate oxygenation. Early intervention may be required to maintain the child's airway.
D. Obtain a specimen for throat culture.: A throat culture should not be obtained in suspected epiglottitis, as manipulating the throat could cause complete airway obstruction. Immediate intervention to secure the airway is the priority.
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