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?

Assign clients to the remaining staff.

Document objective findings about the situation.

Remove the nurse from the client care area.

Call the supervisor to ask for another nurse.

Answer and Explanation

The Correct Answer is C

Explanation:

When a charge nurse observes the smell of alcohol on a nurse's breath, it raises concerns about their ability to provide safe and competent care to clients. Patient safety is of utmost importance, and the charge nurse must take immediate action to address the situation.

Removing the nurse from the client care area ensures that the nurse is not involved in direct patient care while their ability to provide safe care is in question. This step helps mitigate potential risks to patient safety.

B and D- After removing the nurse from the client care area, further actions can be taken, such as documenting the objective findings about the situation and informing the supervisor. However, the immediate priority is to ensure patient safety by removing the nurse from the care area.

A- Assigning clients to the remaining staff can be done once the situation has been addressed and a suitable replacement for the nurse has been arranged.

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Correct Answer is C

Explanation

Explanation

C. Position the client on their left side

The symptoms of feeling dizzy, racing heart, and becoming pale while lying on their back are consistent with supine hypotensive syndrome or vena cava syndrome. This condition occurs when the pregnant uterus compresses the vena cava, reducing blood flow back to the heart and causing a drop-in blood pressure.

Positioning the client on their left side helps alleviate the pressure on the vena cava, allowing for improved blood flow and preventing further symptoms. This position optimizes blood circulation and reduces the risk of complications. The nurse should assist the client in turning onto their left side and ensure they are comfortable.

Providing the client with a glass of orange juice (option A) is not recommended as it may be helpful in cases of low blood sugar or hypoglycemia, but it is not the most appropriate action in this scenario.

Instructing the client to take a brisk walk (option B) is not recommended since physical exertion can further worsen the symptoms and increase the risk of complications.

Checking the client's temperature (option D) is not necessary as the reported symptoms are not indicative of a fever or infection.

Therefore, the most appropriate action for the nurse to take in this situation is to position the client on their left side (option C).

A. Hyperglycemia B. Hypertension C. Hematuria, D. Tinnitus

Correct Answer is B

Explanation

Explanation

B.Hypertension

Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. One of the potential adverse effects of MAOIs is hypertensive crisis, which can be triggered by the consumption of foods high in tyramine. Tyramine-rich foods, such as aged cheeses, cured meats, certain wines, and fermented products, can cause the release of norepinephrine, leading to a sudden increase in blood pressure.

Monitoring the client for hypertension is crucial because a hypertensive crisis can be life-threatening. Signs and symptoms of hypertensive crisis may include severe headache, chest pain, palpitations, blurred vision, anxiety, and shortness of breath. If these symptoms occur, immediate medical intervention is required.

The other options are not specifically associated with the adverse effects of tranylcypromine:

Hyperglycemia in (option A) is not typically associated with tranylcypromine. However, it is important to monitor blood glucose levels in clients with pre-existing diabetes, as tranylcypromine can affect blood sugar control.

Hematuria (blood in the urine) in (option C) is not a common adverse effect of tranylcypromine.

Tinnitus (ringing in the ears) in (option D) is not a commonly reported adverse effect of tranylcypromine.

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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?

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Naxlex Comprehensive Predictor Exams

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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?