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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice B rationale:

Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:

Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.

Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.

Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.

Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.

Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.

Rationale for Other Choices:

Choice A: Administering a prescribed analgesic:

While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.

Choice C: Notifying the provider:

Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.

Choice D: Offering oral fluids:

Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.

A. Recap needles and place them in a wastebasket. B. Do not recap the needle on an ABG specimen. C. Place uncapped needles in a puncture-proof container after use. D. Break needles in half before putting them in the sharps disposal box.

Correct Answer is C

Explanation

Choice A rationale:

Recapping needles is a dangerous practice that significantly increases the risk of needlestick injuries.

The act of recapping involves directing the sharp end of the needle towards one's hand, creating a high likelihood of accidental puncture.

Even experienced healthcare professionals are susceptible to needlestick injuries during recapping.

Wastebaskets are not designed for the safe disposal of sharps and can easily be punctured, leading to potential exposure to bloodborne pathogens.

Choice B rationale:

While it is true that needles should not be recapped on ABG specimens, this option does not address the broader issue of safe needle disposal in general.

Focusing solely on ABG specimens could lead to the misconception that recapping is acceptable for other types of needles.

Choice D rationale:

Breaking needles in half is not recommended as a standard practice for needle disposal.

This action can create sharp fragments that are difficult to handle and can still cause injuries.

Sharps disposal containers are designed to safely contain intact needles and should be used as the primary method of disposal.

Choice C rationale:

Placing uncapped needles directly into a puncture-proof container is the safest and most recommended practice for needle disposal.

These containers are specifically designed to prevent needlestick injuries by shielding the sharps from accidental contact. They are typically made of hard plastic or metal and are clearly labeled for biohazard waste.

Using puncture-proof containers consistently for all needle disposal significantly reduces the risk of needlestick injuries among healthcare workers.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a group of newly licensed nurses about preventing needlestick injuries. Which of the following actions should the nurse recommend?

Correct Answer is C

Explanation

A nurse is collecting data about the fluid status of four patients.Which patient should the nurse identify as being at risk for fluid volume deficit?

A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy.Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?

In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?

A nurse is caring for a patient experiencing pain related to a musculoskeletal disorder. Which statement about chronic pain is most accurate?

A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse’s first response?

A male patient informs the nurse that he prefers not to have female assistive personnel (AP) involved in his care. Which response should the nurse provide?

A nurse is caring for a patient who is postoperative and receiving fentanyl via patient-controlled analgesia. The patient has a prescription for naloxone. What is the purpose of naloxone?

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?