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?

Assign clients to the remaining staff.

Document objective findings about the situation.

Remove the nurse from the client care area.

Call the supervisor to ask for another nurse.

Answer and Explanation

The Correct Answer is C

When a charge nurse observes the smell of alcohol on a nurse's breath, it raises concerns about their ability to provide safe and competent care to clients. Patient safety is of utmost importance, and the charge nurse must take immediate action to address the situation.

Removing the nurse from the client care area ensures that the nurse is not involved in direct patient care while their ability to provide safe care is in question. This step helps mitigate potential risks to patient safety.

B and D- After removing the nurse from the client care area, further actions can be taken, such as documenting the objective findings about the situation and informing the supervisor. However, the immediate priority is to ensure patient safety by removing the nurse from the care area.

A- Assigning clients to the remaining staff can be done once the situation has been addressed and a suitable replacement for the nurse has been arranged.

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Correct Answer is C

Explanation

Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.

Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.

Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.

Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.

A. Giving change-of-shift report to a nurse outside the client's room B. Discussing a client's prognosis with an assistive personnel who is caring for the client C. Writing a client's diagnosis on the message board in the client's room D. Discarding worksheets containing client information in a wastebasket

Correct Answer is A

Explanation

A.Giving change-of-shift report to a nurse outside the client's room ensures that client information is shared in a private, secure setting, reducing the risk of unauthorized individuals overhearing sensitive information.

B.While sharing information with staff involved in the client's care is generally acceptable, discussing detailed prognosis with assistive personnel (who may not have a need-to-know role) is inappropriate. Confidential information should only be shared with those directly involved in the patient's care as part of the care team.

C.This is a clear violation of confidentiality, as it exposes the client's private health information to anyone who may access the room.

D.This is a breach of confidentiality, as the information could be accessed by unauthorized individuals. The appropriate way to dispose of confidential information is to shred it or return it to the medical record.

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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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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?