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:
Abnormal Involuntary Movement Scale is correct. The Abnormal Involuntary Movement Scale (AIMS) is a standardized tool used to assess and identify tardive dyskinesia, a side effect of antipsychotic medications. Tardive dyskinesia involves involuntary, repetitive movements, typically involving the face, mouth, and sometimes other body parts. Regular monitoring using the AIMS helps healthcare providers detect and evaluate the severity of these abnormal movements, allowing for appropriate management and intervention as needed.
Choice B Reason:
Mental Status Examination (MSE) is incorrect. The MSE is a comprehensive assessment of a person's mental state and cognitive function. While it is valuable for assessing a person's overall mental health and cognitive status, it is not specific for identifying tardive dyskinesia, which is a specific movement disorder.
Choice C Reason:
Brief Psychiatric Rating Scale (BPRS) is incorrect. The BPRS is a tool used to assess the severity of psychiatric symptoms and their changes over time. It is not specific for identifying the physical movements associated with tardive dyskinesia.
Choice D is incorrect:
Patient Health Questionnaire (PHQ) is incorrect. The PHQ is a self-report tool used to screen for symptoms of depression and anxiety. It is not designed for identifying movement disorders like tardive dyskinesia, which are characterized by abnormal physical movements.
Correct Answer is D
Explanation
Choice A Reason:
Clammy skin is incorrect. DKA is more likely to cause dry or flushed skin due to dehydration and the effects of high blood sugar levels. Clammy skin is usually associated with conditions that cause excessive sweating.
Choice B Reason:
Bounding pulse is incorrect. DKA can lead to tachycardia (a rapid heart rate) as the body tries to compensate for the metabolic imbalances, but a bounding pulse is not a characteristic finding of DKA.
Choice C Reason:
Elevated blood pressure is incorrect. DKA is more likely to result in an initial decrease in blood pressure due to dehydration. Elevated blood pressure may be present in other conditions but is not a primary feature of DKA.
Choice D Reason:
Fruity breath odor is correct. Diabetic ketoacidosis (DKA) is a serious complication of diabetes characterized by a buildup of ketones in the blood, which results from the body breaking down fat for energy due to a lack of insulin. Fruity breath odor, often described as smelling like acetone or nail polish remover, is a classic sign of DKA. It occurs because the presence of ketones in the blood leads to the exhalation of acetone through the breath.
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