A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

Choice A rationale:

Administering an enema can help relieve the client’s abdominal cramping and small, hard, painful bowel movement. An enema is a procedure that involves introducing a liquid solution into the rectum to promote evacuation of feces. It can be used to relieve constipation, which seems to be the client’s issue based on the description of their bowel movement.

Choice B rationale:

Assisting the client with a sitz bath may not be necessary at this time. A sitz bath is typically used to soothe and cleanse the perineal area, particularly after childbirth or surgery. While the client does have a surgical incision, the notes indicate that the perineal dressing is intact with minimal serosanguinous drainage, suggesting that the incision site is not currently problematic.

Choice C rationale:

Irrigating an indwelling catheter with 500 mL of fluid is not recommended unless there is a specific indication, such as the catheter being blocked. The client’s urinary catheter is intact with 100 mL/hr of pink urine, which suggests that it is functioning properly.

Choice D rationale:

Encouraging prolonged dangling before ambulation may not be beneficial for this client. Dangling involves sitting on the edge of the bed with legs hanging down before standing up. This can help prevent dizziness upon standing. However, the notes indicate that the client is already ambulating independently in the hallway, suggesting that they do not have issues with mobility or dizziness.

Choice E rationale:

Encouraging oral fluid intake can help alleviate constipation by softening stools and promoting bowel movements. It can also help maintain hydration, which is particularly important for postoperative clients. Therefore, this would be a beneficial action for the nurse to take for this client.

Choice A rationale:

Calling the supervisor to ask for another nurse is not the first action the charge nurse should take when noticing the smell of alcohol on a nurse's breath. While it's important to involve the supervisor, immediate action to ensure patient safety is required.

Choice B rationale:

Documenting objective findings about the situation is a valid step in the process, but it should not be the first action. The charge nurse's primary responsibility is to address the immediate safety concerns.

Choice C rationale:

Removing the nurse from the client care area is the first action the charge nurse should take when smelling alcohol on a nurse's breath. This action ensures patient safety and prevents potential harm caused by impaired nursing care.

Choice D rationale:

Assigning clients to the remaining staff is not the first action to take when there is suspicion of alcohol impairment in a nurse. Patient safety and addressing the situation involving the impaired nurse take precedence.