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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Ciprofloxacin is an antibiotic commonly prescribed for the treatment of various bacterial infections. It belongs to a class of medications known as fluoroquinolones. One potential side effect of ciprofloxacin is increased sensitivity to sunlight, which can lead to a higher risk of sunburn. Therefore, it is important for the client to take precautions, such as using sunscreen, wearing protective clothing, and avoiding excessive sun exposure while taking this medication.
"Take an antacid if the medication causes gastrointestinal upset": Ciprofloxacin can be taken with or without food, but it should not be taken with antacids, calcium supplements, or other products containing aluminum, magnesium, or calcium, as they can interfere with the absorption of the medication. If gastrointestinal upset occurs, it is generally recommended to take the medication with food to minimize this side effect.
"Restrict your daily fluid intake while taking this medication": There is no need to restrict fluid intake while taking ciprofloxacin unless specifically instructed by the healthcare provider.
Adequate hydration is important to maintain overall health and prevent potential complications.
"Expect to experience diarrhea while taking this medication": Diarrhea can be a potential side effect of ciprofloxacin, but it is not a universal experience for all individuals taking the medication. It is more appropriate to inform the client about the potential side effects of ciprofloxacin, including gastrointestinal upset, and to encourage them to report any significant or persistent symptoms to their healthcare provider

Correct Answer is B
Explanation
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.

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