A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?
Assign clients to the remaining staff.
Call the supervisor to ask for another nurse.
Remove the nurse from the client care area.
Document objective findings about the situation.
The Correct Answer is C
A. Assign clients to the remaining staff is not the first action. The nurse should address the suspected impairment of the staff member before assigning clients to others.
B. Call the supervisor to ask for another nurse is not the first action. While notifying the supervisor is important, the nurse should first ensure that the impaired nurse is removed from direct client care to prevent any potential harm to clients.
C. Remove the nurse from the client care area is correct. The first priority is to ensure that the nurse who may be impaired is not caring for clients to ensure client safety.
D. Document objective findings about the situation is important but not the first step. The immediate priority is ensuring the safety of clients by removing the nurse from the care area. Documentation can follow after ensuring client safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.
B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.
C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.
D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.
Correct Answer is B
Explanation
A. "Replace the ear molds once per year" is incorrect. Ear molds should be checked regularly for wear and tear, but they should be replaced as needed rather than on a fixed schedule like once a year.
B. "Clean the hearing aid with a soft cloth" is correct. Cleaning the hearing aid with a soft cloth helps to maintain the device, removing dirt and debris without damaging the electronics. It is important to avoid using harsh chemicals or abrasive materials that could harm the hearing aid.
C. "Disinfect the hearing aid with isopropyl alcohol" is incorrect. Isopropyl alcohol is too harsh for cleaning hearing aids and can damage the components. The hearing aid should only be cleaned with appropriate methods, such as a dry cloth or cleaning brush.
D. "Change the battery once per month" is incorrect. The battery should be checked more frequently, as it typically needs to be replaced more often (e.g., every 7-10 days), depending on usage. Changing it once a month may not ensure optimal performance.
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