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 B
Explanation
Choice B rationale:
Stridor is a high-pitched, whistling sound that is heard during inspiration. It is a sign of upper airway obstruction, indicating a potentially life-threatening complication that requires immediate intervention.
Here's a detailed explanation of why stridor is the most concerning finding and why the other choices are not as indicative of a serious problem:
Stridor:
Mechanism: Stridor occurs when there is narrowing or obstruction of the upper airway, typically at the level of the larynx or trachea. This narrowing can be caused by various factors, including:
Laryngospasm: A sudden constriction of the vocal cords, often triggered by irritation or inflammation. Post-extubation edema: Swelling of the tissues in the airway after removal of the endotracheal tube.
Mucus plugging: Accumulation of thick secretions in the airway, which can partially block airflow.
Vocal cord dysfunction: Impairment of the vocal cords' movement, which can affect their ability to open and close properly.
Significance: Stridor is a serious sign because it indicates that airflow is significantly restricted. If left untreated, upper airway obstruction can lead to hypoxia (low oxygen levels) and respiratory failure.
Nursing intervention: If stridor is present, the nurse should immediately notify the provider and prepare for potential interventions to secure the airway, such as:
Reintubation: Reinserting the endotracheal tube to bypass the obstruction.
Nebulized racemic epinephrine: Medication to reduce swelling in the airway.
Heliox: A mixture of helium and oxygen that can improve airflow through a narrowed airway. Steroids: Medications to reduce inflammation in the airway.
Crackles (Choice A):
Description: Crackles are rattling, crackling sounds heard in the lungs, often during inspiration. They are typically associated with lower airway problems, such as pneumonia or pulmonary edema.
Significance: While crackles can indicate respiratory issues, they are not as immediately concerning as stridor in the context of post-extubation care.
Strong cough (Choice C):
Significance: A strong cough is generally a positive sign after extubation, as it indicates that the patient is able to clear secretions from their airway effectively.
Deep breathing (Choice D):
Significance: Deep breathing is also a positive sign, as it promotes lung expansion and oxygenation.
Correct Answer is B
Explanation
Establishing an open airway is the most crucial and immediate action in any respiratory arrest situation, including when a client has heart failure. Here's a detailed explanation: 1. Airway patency is paramount for survival: Oxygen, the essential element for life, cannot reach the lungs and bloodstream without a clear and unobstructed airway. Brain cells are extremely sensitive to oxygen deprivation and start to die within minutes without it, leading to irreversible brain damage or death. 2. Respiratory arrest in heart failure: Heart failure often leads to fluid buildup in the lungs (pulmonary edema), which can significantly impair breathing. Respiratory arrest can occur due to: Excessive fluid accumulation in the lungs. Weakening of respiratory muscles due to fatigue or heart failure itself. Arrhythmias or heart blocks affecting heart's ability to pump effectively. 3. Steps to establish an open airway: Head tilt-chin lift maneuver: Gently tilt the head back and lift the chin to open the airway. Jaw thrust maneuver: If a neck injury is suspected, use the jaw thrust maneuver to avoid further injury. Removal of any visible obstructions: Clear any visible foreign objects or fluids from the mouth or throat. Use of airway adjuncts: Consider using oral or nasal airways to maintain airway patency, especially if the patient is unconscious.
4. Rationale for other choices:
A. Auscultating for breath sounds: While important for assessment, it does not address the immediate need to establish airflow.
C. Establishing IV access: IV access is necessary for medications and fluids, but airway takes priority in respiratory arrest.
D. Feeling for a carotid pulse: Checking for a pulse is essential, but only after ensuring an open airway and attempting to restore breathing.
5. Importance of prioritizing airway: Establishing an open airway allows for potential rescue breaths and ventilation, which can help restore oxygen levels and prevent further deterioration. Even if a pulse is present, without a clear airway, oxygen cannot reach the vital organs, leading to organ failure and death.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today