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:
Telling the client to discuss the decision with her family implies that the family should influence or make the decision for the client. The decision to continue or discontinue treatment is a personal one that the client should make based on their own values and preferences.
Choice B Reason:
Supporting the client's decision to stop the treatment is correct. When a client with end-stage kidney disease decides to stop dialysis treatment, it's essential for the nurse to respect the client's autonomy and support their decision. The client has the right to make decisions about their own healthcare, including the decision to discontinue a treatment that is no longer aligned with their goals and wishes.
Choice C Reason:
Discussing alternative treatment methods may be appropriate in some cases, but if the client has made an informed decision to stop dialysis, the focus should be on respecting and supporting that decision rather than presenting alternatives.
Choice D Reason:
Involving the facility chaplain may be beneficial if the client desires spiritual or emotional support during this difficult decision-making process, but it should be at the client's request, not imposed by the nurse.
Correct Answer is D
Explanation
Choice A Reason:
Chloasma is incorrect. Chloasma, also known as the "mask of pregnancy," refers to the brownish or tan patches of pigmentation that can appear on the face during pregnancy. It is not related to the purplish discoloration of the cervix, vagina, and vulva described in the scenario.
Choice B Reason:
Hegar's sign is incorrect. Hegar's sign is a softening and compressibility of the lower uterine segment (the area between the cervix and the body of the uterus) that can be felt during a pelvic examination. It is not related to discoloration of the genital area.
Choice C Reason:
Ballottement is incorrect. Ballottement is a technique used during a pelvic examination to assess the fetus's position and is characterized by the examiner feeling a rebound movement of the fetus when it is pushed and then released. It does not involve discoloration of the genital area.
Choice D Reason:
Chadwick's sign is a bluish-purple or purplish discoloration of the cervix, vagina, and vulva that can occur during pregnancy. This discoloration is due to increased blood flow to the pelvic area and is considered a normal physiological change during pregnancy. It is one of the early signs of pregnancy and can be observed as early as the sixth week of gestation. It is named after the American obstetrician James Read Chadwick, who first described it.
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