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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "It is my responsibility to obtain informed consent from the client prior to the procedure." is incorrect. It is the provider's responsibility to explain the procedure, its risks, benefits, and alternatives to the client, not the nurse's. The nurse's role is to witness the signing of the consent form.
B. "I will sign the consent form to indicate that the client has received written materials explaining the procedure." is incorrect. The nurse's role is to witness the client's signature, but the nurse does not sign to indicate that the client has received written materials.
C. "I will provide the client with an explanation of the procedure before I sign the consent form." is incorrect. The nurse should not provide the explanation of the procedure; this is the responsibility of the provider. The nurse ensures that the client understands and is signing voluntarily.
D. "When I sign the consent form, I am stating that the client appears to be competent to give consent." is correct. The nurse’s role is to witness the signing of the consent form and ensure that the client appears to be competent to provide consent. The nurse does not provide the explanation but confirms that the client is signing voluntarily and understands the procedure.
Correct Answer is B
Explanation
A. Sit on the client's right side. This is not the best approach. If the client has hearing loss in one ear, the nurse should sit on the side of the client’s better ear, not necessarily the right side.
B. Choose a room that is well-lit and free from background noise. This is the correct choice. A well-lit room helps the client read lips or better perceive any non-verbal cues. Reducing background noise ensures the client can focus on hearing or understanding speech without distractions.
C. Exaggerate lip movement while speaking. While some individuals with hearing loss may rely on lip-reading, exaggerating lip movement can make it more difficult to understand. It is more effective to speak clearly without overemphasizing movements.
D. Ask a few questions at a time. This is not the best strategy. It is better to ask one clear, simple question at a time to ensure the client understands, as too many questions at once can overwhelm them.
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