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:
Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.
Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)
Infection
Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)
Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.
Choice A rationale:
Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.
Choice C rationale:
Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.
Choice D rationale:
Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.
Correct Answer is D
Explanation
The correct answer is choice d. Auscultate lung fields.
Choice A rationale:
Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.
Choice B rationale:
Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.
Choice C rationale:
Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.
Choice D rationale:
Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.
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