A staff nurse suspects that a newly licensed nurse is chemically impaired. Which of the following actions should the staff nurse take?

The correct answer is Choice C.

Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.

Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.

Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.

If a float nurse is given a client assignment that requires the use of unfamiliar skills and techniques, the appropriate action for the nurse to take is to request that the charge nurse modify the assignment. This will allow the nurse to provide safe and competent care to their clients.
Option A is incorrect because providing client care as assigned without the necessary skills and knowledge could compromise client safety.
Option C is incorrect because making a formal complaint to the nursing manager is not an immediate solution to the issue at hand.
Option D is incorrect because asking another nurse to trade assignments may not be feasible or appropriate.