A nurse on the unit suspects that a colleague is extracting a small quantity of morphine from the syringe prior to administering it to the patient.
What should the nurse do in this situation?
Inform the charge nurse about her suspicion.
Report the incident to the hospital’s security department.
Request the assistive personnel (AP) to monitor the other nurse’s actions.
Confront the other nurse to discuss her suspicions.
The Correct Answer is A
Choice A rationale:
It is crucial for the nurse to prioritize patient safety and adhere to professional guidelines when encountering a potential diversion of controlled substances. Informing the charge nurse is the most appropriate initial action for several reasons:
Chain of Command: The charge nurse holds a supervisory position and is responsible for addressing issues within the unit, including concerns about medication diversion. Reporting suspicions to the charge nurse ensures adherence to the established chain of command and facilitates a prompt, organized response.
Confidentiality and Objectivity: The charge nurse is trained to handle sensitive situations discreetly and objectively. They can initiate a thorough investigation while maintaining confidentiality and protecting the rights of all involved parties.
Access to Resources: The charge nurse has access to resources and authority to take immediate action, such as securing medications, initiating patient assessments, and notifying appropriate personnel within the healthcare facility.
Collaboration and Support: The charge nurse can provide guidance and support to the reporting nurse, ensuring their concerns are addressed appropriately and that they feel safe in coming forward with their suspicions.
Rationale for other choices:
B. Reporting the incident directly to the hospital’s security department might be premature without first informing the charge nurse. The charge nurse can assess the situation, gather more information, and determine the most appropriate course of action, which may or may not involve security at this initial stage.
C. Requesting assistive personnel (AP) to monitor the other nurse’s actions is inappropriate. It places a burden on APs who are not trained or authorized to investigate such matters. It could also compromise the integrity of the investigation and potentially jeopardize patient safety.
D. Confronting the other nurse directly is not recommended. It could escalate the situation, create a hostile work environment, and potentially compromise the investigation. It is essential to follow established protocols and involve appropriate personnel to ensure a fair and thorough investigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).
Early ambulation is generally encouraged to promote circulation and prevent blood clots.
Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.
Choice B rationale:
Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.
The patient's position should be based on their individual needs and comfort level.
In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.
Choice C rationale:
Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.
This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.
Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.
Choice D rationale:
Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.
This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.
If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.
Correct Answer is B
Explanation
Choice A rationale:
Malnutrition is a risk factor for HAIs, but it is not a common cause. Malnutrition weakens the immune system, making it less able to fight off infection. However, malnutrition is not directly responsible for the introduction of pathogens into the body, which is a necessary step for the development of an HAI.
Choice C rationale:
Multiple caregivers can contribute to the spread of pathogens, but it is not a common cause of HAIs. When multiple caregivers are involved in a patient's care, there is a greater chance that one of them may be carrying a pathogen and transmit it to the patient. However, this is not the most common way that HAIs are spread.
Choice D rationale:
Chlorhexidine washes are actually used to prevent HAIs, not cause them. Chlorhexidine is an antiseptic that kills bacteria and other pathogens. It is often used to clean the skin before surgery or other invasive procedures.
Choice B rationale:
Urinary catheterization is a common cause of HAIs. A urinary catheter is a tube that is inserted into the bladder to drain urine. Catheters can introduce bacteria into the bladder, which can lead to urinary tract infections (UTIs). UTIs are the most common type of HAI.
Here are some of the reasons why urinary catheterization is a common cause of HAIs:
Catheters can introduce bacteria into the bladder. The catheter itself can act as a conduit for bacteria to enter the bladder. Bacteria can also enter the bladder around the catheter, where the catheter enters the urethra.
Catheters can irritate the bladder. This can make the bladder more susceptible to infection. Catheters can obstruct the flow of urine. This can allow bacteria to grow in the bladder.
Catheters can be difficult to keep clean. This can increase the risk of bacteria growing on the catheter and being introduced into the bladder.
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