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.

Remove the nurse from the client care area.

Assign clients to the remaining staff.

Document objective findings about the situation.

Answer and Explanation

The Correct Answer is B

Explanation: The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.

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Correct Answer is C

Explanation

The correct answer is choice C. Clean the stoma using an inward to outward circular motion.

Choice A rationale:

Cleansing the inner cannula with isopropyl alcohol is not recommended because it can be irritating to the mucosa. Instead, the inner cannula should be cleaned with sterile saline or a prescribed solution.

Choice B rationale:

Preparing sterile supplies after removing the inner cannula is not the correct sequence. Sterile supplies should be prepared before starting the procedure to maintain sterility and efficiency.

Choice C rationale:

Cleaning the stoma using an inward to outward circular motion is correct because it helps to prevent the spread of microorganisms from the outer skin to the stoma site, reducing the risk of infection.

Choice D rationale:

Ensuring at least three finger widths of space under tracheostomy ties is incorrect. The correct practice is to ensure that only one to two finger widths can fit under the tracheostomy ties to ensure they are secure but not too tight.

A. Monitor the client's range of motion every 60 min. B. Offer the client a nutritious snack every 4 hr. C. Plan to remove the restraints as soon as the client is calm D. Ensure that the provider has signed a prescription for restraints within 48 hr.

Correct Answer is C

Explanation

The correct answer is C. Plan to remove the restraints as soon as the client is calm. Physical restraints should be used as a last resort and for the shortest duration possible to ensure

client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.

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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 is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?

Correct Answer is C

Explanation

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