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 A

Explanation

Choice A Reason:

Changing a central venous catheter dressing for a client who is receiving IV therapy is correct. Sterile gloves should be used when performing procedures that involve the manipulation of sterile or aseptic areas, such as changing the dressing on a central venous catheter. Maintaining the sterility of the catheter site is crucial to prevent infections in clients receiving IV therapy through central lines.

Choice B Reason:

Instilling an ophthalmic ointment for a client with a corneal abrasion involves applying a medication to the eye is incorrect. While it's important to use clean technique and maintain good hand hygiene, it does not require sterile gloves.

Choice C Reason:

Inserting an NG (nasogastric) tube for enteral feedings is a clean procedure, not a sterile one. Clean gloves are typically used to maintain cleanliness and reduce the risk of infection, but full sterile technique is not necessary.

Choice D Reason:

Administering an IM (intramuscular) injection also does not require sterile gloves. Clean gloves should be used to maintain infection control, but full sterile technique is not needed for routine IM injections.

A. Support the extremity above and below each joint during the exercises. B. Repeat each exercise movement 10 times. C. Position the bed at mid-thigh level. D. Move each joint just past the point of resistance.

Correct Answer is A

Explanation

This is an essential instruction for performing passive ROM exercises safely and effectively. Supporting the extremity above and below each joint helps to prevent injury and provides stability during the exercise. This technique also helps to minimize discomfort and maintain proper alignment of the joint.

Repeat each exercise movement 10 times: This instruction does not provide sufficient guidance on the number of repetitions and may be too general. The number of repetitions will depend on the client's condition and tolerance.

Position the bed at mid-thigh level: This instruction is not necessary for performing passive ROM exercises and may not be feasible in all settings.

Move each joint just past the point of resistance: This instruction can be harmful and may cause injury or pain. The nurse should encourage the family to move the joint gently and smoothly, within the range of motion that is comfortable for the client.

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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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Correct Answer is A

Explanation

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