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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Correct Answer is C

Explanation

To elicit the Moro reﬂex, the nurse should clap hands after laying the newborn on a ﬂat surface. The Moro reﬂex, also known as the startle reﬂex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reﬂex.

Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reﬂex.

Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reﬂex, not the Moro reﬂex.

Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reﬂex.

A. Restrict the client's ﬂuid intake B. Keep suction equipment at the client's bedside C. Instruct the client to look down when ambulating D. Position the client supine after eating

Correct Answer is B

Explanation

b. Keep suction equipment at the client's bedside.

The nurse should plan to include keeping suction equipment at the client's bedside as an intervention for a client with Parkinson's disease. Parkinson's disease can cause dysphagia (difficulty swallowing) and an increased risk of aspiration. Having suction equipment readily available allows for prompt intervention in case of choking or aspiration episodes, ensuring the client's safety.

Explanation for the other options:

a. Restrict the client's ﬂuid intake: Restricting the client's ﬂuid intake is not typically indicated in the care of a client with Parkinson's disease. Adequate hydration is important for overall health and well-being. However, specific ﬂuid restrictions may be necessary in certain situations, such as if the client has coexisting conditions like heart failure or kidney disease, which should be assessed and determined by the healthcare provider.

c. Instruct the client to look down when ambulating: In Parkinson's disease, individuals often experience a forward-ﬂexed posture and a shuﬄing gait. Instructing the client to look down when ambulating is not an appropriate intervention. Instead, the nurse should encourage the client to maintain an upright posture, take smaller steps, and focus on taking deliberate and controlled movements to promote stability and reduce the risk of falls.

d. Position the client supine after eating: Positioning the client supine after eating is not recommended for a client with Parkinson's disease. This position can increase the risk of aspiration, as it may promote reﬂux and regurgitation of stomach contents. Instead, the nurse should advise the client to maintain an upright position, such as sitting in a chair or using a recliner with appropriate head support, to aid digestion and reduce the risk of aspiration.

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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

A nurse in the newborn nursery is collecting data about a newborn's Moro reﬂex. Which of the following actions should the nurse take to elicit this reﬂex?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has Parkinson's disease. Which of the following interventions should the nurse plan to include?

Correct Answer is B

Explanation

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