A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take?

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.

Choice A Reason:

Explaining the procedure's purpose is incorrect. While explaining the procedure's purpose is essential, it should not be done as a sole response if the client has expressed a lack of understanding. The client's concerns and questions need to be addressed first.

Choice B Reason:

Reminding the client about the specifics of the procedure is incorrect. This choice assumes that the client is aware of the specifics but has forgotten them. If the client has already stated that they don't understand why the procedure is necessary, simply reminding them of the details may not address their concerns adequately.

Choice C is Reason:

Asking the client to sign the consent form anyway is incorrect. This option is not appropriate because it would violate the principle of informed consent. Informed consent requires that the client fully understands the procedure, its purpose, potential risks, and alternatives before signing the form. If the client doesn't understand, signing the form would not be informed consent.

Choice D Reason:

Notifying the charge nurse about the situation is correct. When a client expresses a lack of understanding or confusion about a medical procedure, it is essential to ensure that the client fully comprehends the procedure, its purpose, potential risks, and alternatives. The nurse should not proceed with obtaining informed consent if the client does not understand. Instead, the charge nurse or another healthcare provider should be notified to address the client's concerns and provide further clarification. It's crucial to prioritize the client's right to make an informed decision regarding their healthcare.