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 D
Explanation
Choice A Reason:
Loose stools are not a typical side effect of radiation therapy for throat cancer. Gastrointestinal side effects may occur, but they are more likely to involve symptoms such as nausea, diarrhea, or difficulty swallowing.
Choice B Reason:
Bladder infection is not directly related to radiation therapy for throat cancer. The side effects of radiation therapy typically pertain to the area being treated, such as the throat and surrounding tissues.
Choice C Reason:
Increased appetite is also not a common side effect of radiation therapy. Many clients may experience a decreased appetite or difficulty eating due to the side effects of radiation, such as mucositis (inflammation of the mouth and throat) or dysgeusia.
Choice D Reason:
Loss of taste is correct . Clients who receive external radiation therapy for throat cancer can experience various side effects due to the radiation's impact on the surrounding tissues. One common side effect is a loss of taste or changes in taste perception, which is known as dysgeusia. This occurs because radiation can damage taste buds and the salivary glands, leading to alterations in taste sensation. Clients may describe a metallic or bitter taste in their mouths or have difficulty tasting certain foods.
Correct Answer is C
Explanation
c. Physical assessment findings
Physical assessment findings are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort.
This information is essential for the physical therapist to develop an appropriate treatment plan for the client. Family medical history and medical health insurance claims may be important for overall client care, but are not directly relevant to a referral for a physical therapist.
Medications taken prior to admission may be relevant if they affect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.
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