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:

Time of last pain medication is correct. This is important for the oncoming nurse to know to ensure timely pain management for the client.

Choice B Reason:

Preferred bath time is incorrect. While it's important to respect the client's preferences, the timing of their bath is typically not as critical to include in the change-of-shift report, especially when compared to more vital information like medication timing.

Choice C Reason:

Admission vital signs is incorrect. Vital signs taken upon admission are usually documented in the client's chart and are not typically included in change-of-shift reports unless there has been a significant change or concern with the client's vital signs during the shift.

Choice D Reason:

Steps required for dressing change is incorrect. While important for the client's care, the specific steps for a dressing change are typically documented in the client's care plan or orders and may not need to be repeated in every shift report unless there's a specific issue or change in the dressing change procedure.

A. Raises all four side-rails on the client's bed B. Assists the client to the bathroom every 2 hr C. Clears furniture from the path leading to the bathroom D. Locks the wheels on the client's bed

Correct Answer is A

Explanation

Choice A Reason:

Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.

Choice B Reason:

Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.

Choice C Reason:

Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.

Choice D Reason:

Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.

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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?

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