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:
Keeping legs in a dependent position (hanging down) is generally not recommended after vein stripping surgery, as it can increase swelling. Elevation of the leg is often recommended to reduce swelling and improve blood flow.
Choice B Reason:
Wrapping the leg with an elastic bandage is correct. When providing discharge teaching to a client who has undergone vein stripping of the right leg, the nurse should include instructions for post-operative care. Wrapping the leg with an elastic bandage is a common practice to help reduce swelling, provide support to the leg, and promote healing. Proper application of the bandage helps with compression and prevents complications like hematoma formation.
Choice C Reason:
Maintaining bed rest for 48 hours is not typically required after vein stripping surgery. Early ambulation and movement are encouraged to prevent blood clots and promote healing.
Choice D Reason:
Implementing a sodium-restricted diet is not directly related to post-operative care for vein stripping surgery. Dietary restrictions should be discussed with a healthcare provider, but they are not a routine part of post-operative instructions for this procedure.
Correct Answer is C
Explanation
Choice A Reason:
Applying talcum powder daily after bathing is not recommended, as it can pose a risk to the baby's respiratory health if inhaled.
Choice B Reason:
The water for a baby's bath should be comfortably warm, but it should not be as hot as 96 degrees Fahrenheit, as this can scald the baby's delicate skin.
Choice C Reason:
"Perform sponge baths until the baby's umbilical cord falls off." This is true. This is because newborns typically receive sponge baths until their umbilical cord stump naturally falls off, which usually occurs within the first few weeks of life. It's important to keep the area around the umbilical cord clean and dry to prevent infection. The other options are not recommended:
Choice D Reason:
Using an alkaline soap is not recommended for newborns, as their skin is sensitive. Mild, fragrance-free, and pH-balanced baby soap is typically recommended for baby's bath.
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