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?

Call the supervisor to ask for another nurse.

Assign clients to the remaining staff.

Document objective findings about the situation.

Remove the nurse from the client care area.

Answer and Explanation

The Correct Answer is D

The presence of alcohol on a nurse's breath raises concerns regarding impairment and the potential for compromised patient safety. It is crucial to prioritize patient safety and prevent any potential harm. Removing the nurse from the client care area ensures that immediate patient safety is addressed and minimizes the risk of any adverse events.

Call the supervisor to ask for another nurse: While involving the supervisor is important, it should not be the first action taken in this situation. The immediate priority is to address patient safety by removing the nurse from the client care area.

Assign clients to the remaining staff: Assigning clients to the remaining staff should not be the first action taken because it may compromise patient safety if the nurse in question is impaired. It is important to ensure that the nurse is removed from the client care area before reassigning the clients to other staff members.

Document objective findings about the situation: Documenting the objective findings about the situation is important for accurate record-keeping and reporting. However, it should not be the first action taken when immediate patient safety is at stake. Removing the nurse from the client care area is the priority.

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Related Questions

A. Constipation: Constipation is not a common or significant side effect of cefazolin. While antibiotics can sometimes cause gastrointestinal disturbances such as diarrhea or nausea, constipation is unlikely to be a major concern for this medication. The adolescent should be encouraged to maintain hydration and a balanced diet, but constipation is not a priority symptom to report in this case. B. Elevated skin patches: Elevated skin patches or rashes could be a sign of an allergic reaction to cefazolin, but this is not the most immediate or critical symptom to monitor for in the context of the question. If an allergic rash develops, the adolescent should certainly report it, but elevated skin patches are more general and not directly associated with a serious or common side effect of cefazolin. Immediate concerns would be other signs of an allergic reaction, such as swelling or difficulty breathing. C. Ringing in the ears: Ringing in the ears (tinnitus) can be a sign of ototoxicity, a known side effect of cefazolin, especially when administered in high doses or for prolonged periods. Ototoxicity can affect hearing and balance, and tinnitus is an early symptom. This is a serious issue that should be reported immediately, as the drug might need to be adjusted or discontinued to prevent permanent damage to the ears. D. Depression: While depression is a serious condition that can affect adolescents, it is not a known side effect of cefazolin. If an adolescent experiences mood changes or symptoms of depression, these should be addressed, but they are unlikely to be directly related to the medication. Depression should always be taken seriously and managed, but it is not a primary concern related to cefazolin use.

Correct Answer is C

Explanation

c. Ringing in the ears.

Explanation:

Cefazolin is an antibiotic medication that belongs to the class of cephalosporins. While it is generally safe and well-tolerated, it can have potential side eﬀects that should be monitored and reported to the healthcare provider. One of the potential side eﬀects of cefazolin is ototoxicity, which can manifest as ringing in the ears (tinnitus) or other hearing disturbances. If the adolescent experiences any ringing in the ears or changes in hearing while taking cefazolin, it should be reported to the healthcare provider for further evaluation.

Options a, b, and d are not specifically associated with the use of cefazolin. Constipation can occur due to various reasons unrelated to this medication. Elevated skin patches may be indicative of an allergic reaction or other skin condition but are not specific to cefazolin. Depression is not a common side eﬀect of cefazolin and should be evaluated separately if experienced by the adolescent.

A. Inject 20 units of air into the vial of NPH insulin. B. Inject 5 units of air into the vial of regular insulin. C. Withdraw 20 units of NPH insulin from the vial. D. Withdraw 5 units of regular insulin from the vial.

Correct Answer is A

Explanation

Answer: (A) Inject 20 units of air into the vial of NPH insulin.

Rationale:

A) Inject 20 units of air into the vial of NPH insulin:

Injecting air into the vial of NPH insulin is the first step to prevent creating a vacuum, which could make it difficult to withdraw the insulin later. The nurse must inject the corresponding amount of air for the dose needed, ensuring that the insulin can be withdrawn smoothly and accurately without bubbles, which could affect the dose.

B) Inject 5 units of air into the vial of regular insulin:

Injecting air into the regular insulin vial is also necessary before withdrawing the insulin, but it should be done after injecting air into the NPH vial. This sequence ensures that no NPH insulin contaminates the regular insulin vial when the nurse withdraws the doses later.

C) Withdraw 20 units of NPH insulin from the vial:

Withdrawing NPH insulin should be done after air is injected into both vials and after the regular insulin has been drawn up. This sequence prevents the mixing of the two types of insulin and ensures accurate dosing, which is crucial for maintaining the correct blood glucose levels.

D) Withdraw 5 units of regular insulin from the vial:

Withdrawing regular insulin is critical to do before the NPH insulin to prevent contamination of the regular insulin with NPH, which could alter the onset and peak times of the regular insulin. However, it should follow the steps of injecting air into both vials, starting with the NPH vial.

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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 C

Explanation

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Correct Answer is A

Explanation

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