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 A
Explanation
Choice A Reason:
Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.
Choice B Reason:
Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.
Choice C Reason:
Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.
Choice D Reason:
Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.
Correct Answer is B
Explanation
Choice A Reason:
Continuing to eat foods high in vitamin B12 is generally a good dietary choice, but it should be done in a way that minimizes irritation to the inflamed oral tissues. The client should choose foods that are soft and gentle on the mouth.
Choice B Reason:
Consume soft, bland foods is correct. When providing instructions to a client with stomatitis (inflammation of the mouth), it's important to recommend a diet that is gentle on the irritated oral tissues. Consuming soft, bland foods can help minimize further irritation and discomfort. Examples of suitable foods may include mashed potatoes, yogurt, oatmeal, applesauce, and other similar items that are easy to chew and swallow.
Choice C Reason:
Using lemon glycerin swabs is not recommended for clients with stomatitis. Lemon can be acidic and may further irritate the mouth. Glycerin swabs alone may be used for oral care, but the lemon component should be avoided.
Choice D Reason:
Rinsing the mouth with an alcohol-based mouthwash is not advisable for clients with stomatitis. Alcohol-based mouthwashes can be harsh and may exacerbate the irritation and pain associated with stomatitis. Clients should be encouraged to use non-alcoholic, mild oral rinses or saline rinses as recommended by their healthcare provider.
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