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 A

Explanation

Choice A rationale:

Restlessness is a common indicator of unrelieved pain in a client. It suggests that the client is uncomfortable and experiencing discomfort, which could be due to inadequate pain relief. Restlessness may manifest as frequent shifting, fidgeting, and an inability to find a comfortable position. Therefore, choice A is the correct answer as it is a reliable indicator of unrelieved pain.

Choice B rationale:

Urinary retention is not typically associated with unrelieved pain in a client with a spinal epidural for a herniated disc. Urinary retention may result from the effects of the epidural anesthesia itself but is not a specific indicator of unrelieved pain. Therefore, choice B is not the correct answer.

Choice C rationale:

Constipation is not a direct indicator of unrelieved pain related to a spinal epidural. Constipation can occur for various reasons, including medications, decreased mobility, and dietary factors. While pain may contribute to constipation indirectly, it is not a reliable and specific sign of unrelieved pain in this context. Therefore, choice C is not the correct answer.

Choice D rationale:

Difficulty swallowing is not typically associated with unrelieved pain related to a spinal epidural. It may be related to other factors, such as muscle weakness or neurological issues, but it is not a specific indicator of unrelieved pain in this situation. Therefore, choice D is not the correct answer.

A. Position the client supine with legs elevated. B. Measure the client's abdominal girth daily. C. Restrict the client's sodium intake to 3g per day. D. Keep the client's daily protein intake below 0.8 g/kg.

Correct Answer is B

Explanation

Choice A rationale:

Positioning the client supine with legs elevated is not an appropriate intervention for a client with ascites due to cirrhosis. It may help with other conditions, but in ascites, it can increase pressure on the abdomen and worsen fluid accumulation.

Choice C rationale:

Restricting the client's sodium intake to 3g per day is a valid intervention for a client with ascites due to cirrhosis. However, measuring the abdominal girth daily is a more immediate and actionable intervention to monitor the progression of ascites and adjust treatment accordingly.

Choice D rationale:

Keeping the client's daily protein intake below 0.8 g/kg is not the standard practice for managing ascites in cirrhosis. In fact, adequate protein intake is important to prevent malnutrition in these clients, so protein restriction is not recommended unless specifically indicated by a healthcare provider.

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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?