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.

Document objective findings about the situation.

Remove the nurse from the client care area.

Assign clients to the remaining staff.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Calling the supervisor to ask for another nurse is not the first action the charge nurse should take when noticing the smell of alcohol on a nurse's breath. While it's important to involve the supervisor, immediate action to ensure patient safety is required.

Choice B rationale:

Documenting objective findings about the situation is a valid step in the process, but it should not be the first action. The charge nurse's primary responsibility is to address the immediate safety concerns.

Choice C rationale:

Removing the nurse from the client care area is the first action the charge nurse should take when smelling alcohol on a nurse's breath. This action ensures patient safety and prevents potential harm caused by impaired nursing care.

Choice D rationale:

Assigning clients to the remaining staff is not the first action to take when there is suspicion of alcohol impairment in a nurse. Patient safety and addressing the situation involving the impaired nurse take precedence.

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Correct Answer is B

Explanation

Choice A rationale:

Applying a cold compress to the client's calf is not the priority in this situation. The client is reporting pain in the calf, which could be indicative of deep vein thrombosis (DVT), a potentially serious condition. Monitoring the client's oxygen saturation (pulse oximetry) is a more appropriate action to assess for possible DVT complications, such as a pulmonary embolism.

Choice B rationale:

Monitoring the client's pulse oximetry is the correct action in this scenario. Pain in the calf can be a symptom of DVT, which can lead to reduced blood flow and potential oxygenation issues. Monitoring the client's oxygen saturation levels can help identify any oxygenation problems early.

Choice C rationale:

Instructing the client to massage the calf gently is not recommended in this situation, as it may dislodge a clot if DVT is present. Massaging the calf can be harmful and is contraindicated when DVT is suspected.

Choice D rationale:

Maintaining the leg in a dependent position while in bed is not a recommended action in this case. Elevating the leg can help reduce swelling and improve venous return, but it should be done cautiously, especially if DVT is suspected. Monitoring the client's condition and oxygen saturation takes precedence.

A. Document the event in the client's progress notes. B. Submit an incident report to the risk manager. C. Inform the client of the APs' actions. D. Tell the APs to stop the conversation.

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.

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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?