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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Correct Answer is B

Explanation

A. Carrying the baby to the nursery is incorrect. Most facilities require that newborns be transported in a bassinet, not carried, to reduce the risk of accidental drops or abductions.

B. Having an identification band that matches the baby’s band is correct. Hospital security protocols require that the mother and baby wear matching identification bands to ensure the right baby is with the right parent and prevent infant abduction or misidentification.

C. Removing the security band to give to a family member is incorrect. The security band must remain on the mother at all times to verify identity when interacting with the baby. Removing it can compromise security.

D. Taking the baby to the lobby to visit family is incorrect. Many hospitals have strict policies requiring newborns to remain in designated areas for security and infection control reasons. Visitors should come to the mother’s room instead.

A. Verify the amount of TPN solution the client is receiving every 4 hr. B. Place the client in Sims' position for catheter insertion C. Use clean technique when changing the catheter dressing D. Prepare the client for a chest x-ray to verify catheter placement

Correct Answer is D

Explanation

A. Verifying the amount of TPN solution the client is receiving every 4 hours is incorrect. While monitoring the TPN infusion rate is important, the rate and amount are typically verified at the start of the infusion and with each new bag change, not every 4 hours.

B. Placing the client in Sims' position for catheter insertion is incorrect. The preferred position for central venous catheter insertion is Trendelenburg or supine with a slight head turn, which helps dilate the veins and reduce the risk of air embolism.

C. Using clean technique when changing the catheter dressing is incorrect. Central venous catheter care requires sterile technique to prevent infections, including catheter-related bloodstream infections (CRBSIs).

D. Preparing the client for a chest x-ray to verify catheter placement is correct. A chest x-ray is required to confirm correct catheter placement before TPN administration to ensure the catheter tip is in the superior vena cava and to rule out complications like pneumothorax.

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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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