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 A
Explanation
A. Bleach: This is correct. Bleach (sodium hypochlorite. is recommended for disinfecting surfaces contaminated with blood or other body fluids due to its ability to effectively kill bloodborne pathogens, including HIV, which is crucial in a healthcare setting involving AIDS. The CDC recommends a solution of 1:10 dilution of bleach to water for blood spill clean-up.
B. Isopropyl alcohol: This is incorrect. While isopropyl alcohol can disinfect surfaces, it is not as effective as bleach in killing certain viruses, including HIV, in blood spills. It may not be sufficient for complete disinfection after a blood spill.
C. Chlorhexidine: This is incorrect. Chlorhexidine is an antiseptic commonly used for skin disinfection, not for cleaning contaminated surfaces. It is not recommended for disinfecting blood spills.
D. Hydrogen peroxide: This is incorrect. Hydrogen peroxide can be used for cleaning, but it is not as effective as bleach in eliminating certain pathogens like HIV after a blood spill. It also may not have the broad-spectrum disinfecting power needed for bloodborne pathogens.
Correct Answer is A
Explanation
A. Assist with a referral to a home health care agency is correct. If the client has no one to assist them at home after surgery, a home health care agency can provide the necessary support. This is a proactive solution to ensure the client has assistance for postoperative recovery, including monitoring for complications, assistance with mobility, and other care needs.
B. Calling the provider about admitting the client to the facility overnight is incorrect. Outpatient surgery is typically intended for clients who can recover at home, and there is no indication that the client requires overnight admission based solely on the lack of assistance at home.
C. Giving the client a list of home care assistants to contact is incorrect. While this could be helpful, it is the nurse's role to actively assist in arranging care. Referring the client to a list of names without offering concrete help may leave the client in a challenging situation.
D. Contacting the next of kin to assist the client at home is incorrect. Although contacting a relative may be an option, it may not be viable or practical for the client. Home health care offers a more reliable solution, as family members may not always be available to provide consistent care.
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