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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Shrimp salad: Shrimp is a type of shellfish, and shellfish are not allowed in a kosher diet.
Choice B Reason:
Roasted salmon. When caring for a client who follows a kosher diet, it's important to provide food that adheres to kosher dietary laws. Kosher dietary laws prohibit the consumption of certain types of seafood (like shrimp and clams) and pork products (like pulled-pork). Therefore, shrimp salad, clam chowder, and pulled-pork sandwich are not suitable for a kosher diet. Roasted salmon, on the other hand, is an acceptable choice for a kosher diet as long as it has been prepared following kosher guidelines. Fish with fins and scales, such as salmon, are generally considered kosher.
Choice C Reason:
Pulled-pork sandwich: Pork is strictly prohibited in a kosher diet, and any pork-based products, including pulled-pork, are not allowed.
Choice D Reason:
Clam chowder: Clams are considered shellfish, and like other shellfish, they are not permitted in a kosher diet.
Correct Answer is A
Explanation
a. Clean the stoma using an inward to outward circular motion.
When performing tracheostomy care, the nurse should clean the stoma from the inside outward in a circular motion. This technique reduces the risk of introducing pathogens to the stoma site by moving debris away from the incision rather than toward it.
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