A nurse is reviewing the medical record for a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

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.

Based on the given information, the nurse should take the following actions in preparation for surgery:

• Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
• Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
• Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
• Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
• Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

• Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
• Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.