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?

Document objective findings about the situation.

Assign clients to the remaining staff.

Call the supervisor to ask for another nurse.

Remove the nurse from the client care area.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Document objective findings about the situation is incorrect. While documentation is important, it should not be the first action when the charge nurse suspects a colleague is under the influence of alcohol. Patient safety takes precedence, and immediate action to remove the nurse from patient care is necessary to prevent potential harm.

Choice B Reason;

Assigning clients to the remaining staff is incorrect. Assigning clients to other staff members is an appropriate step but should come after the nurse under suspicion has been removed from patient care to ensure their safety. Patient safety is the primary concern.

Choice C Reason:

Calling the supervisor to ask for another nurse is incorrect. Contacting the supervisor is a reasonable action, but it should be done after the immediate safety concern has been addressed by removing the nurse from patient care. This allows the supervisor to be informed of the situation and take appropriate action.

Choice D Reason:

Removing the nurse from the client care area is correct.When a charge nurse detects the smell of alcohol on a nurse's breath, the first and most immediate action should be to remove the nurse from the client care area to ensure patient safety. Alcohol impairment can severely compromise a nurse's ability to provide safe and effective care. Once the nurse is removed from patient care, further actions, such as documenting objective findings and contacting the supervisor, can be taken to address the situation and ensure appropriate follow-up, including any necessary interventions or investigations. Patient safety should always be the top priority in such situations.

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Correct Answer is C

Explanation

Choice A Reason:

"Have you tried leaving your house just once per day?" This response assumes a potential solution without fully understanding the client's feelings. It doesn't encourage open discussion or exploration of the client's anxiety.

Choice B Reason:

"Have you thought about moving to a new neighborhood?" This response jumps to a significant life change as a solution without exploring the client's current situation and emotions. It may not be a practical or necessary step.

Choice C Reason:

"Let's discuss how you feel when you leave your house." This response is an open and therapeutic approach that encourages the client to express their feelings and thoughts about the situation. It allows the nurse to gather more information and better understand the client's anxiety related to leaving the house. The other options do not facilitate open communication or exploration of the client's feelings.

Choice D Reason:

"Tell me why you have developed an aversion to leaving your house." While this response is more open-ended, it phrases the question in a somewhat confrontational manner, which might make the client defensive. The previous response ("Let's discuss how you feel when you leave your house") is gentler and inviting.

A. Administer time-critical medication 60 min before or after the scheduled time. B. Document medication administration prior to administering medication. C. Identify the client by using one identifier before giving the medication. D. Verify the medication three times with the medication administration record.

Correct Answer is D

Explanation

Choice A Reason:

Time-critical medications should generally be given within a specific time frame, usually 30 minutes before or after the scheduled time. Waiting for 60 minutes may lead to suboptimal therapeutic effects or potential complications.

Choice B Reason:

Documentation should occur after medication administration to ensure accuracy. Administering the medication should be confirmed before recording it in the patient's chart.

Choice C Reason:

Correct identification of the patient is crucial to ensure that the medication is given to the right person. Using at least two patient identifiers (e.g., name and date of birth) is a common practice to enhance accuracy.

Choice D Reason:

This is a fundamental safety measure in medication administration. The nurse should check the medication against the medication administration record three times: when removing it from storage, when preparing it, and before administering it to the patient. This helps prevent medication errors.

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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

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Explanation

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Explanation

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