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 A
Explanation
A. "You should not palpate your child's abdomen prior to surgery." is correct. Palpating the abdomen of a child with Wilms' tumor should be avoided, as this could cause the tumor to rupture and spread cancerous cells. The tumor is typically confined to one kidney and must be surgically removed.
B. "Your child should have surgery in 7 to 10 days to remove the tumor." is incorrect. Surgery to remove a Wilms' tumor typically occurs within 24 to 48 hours after diagnosis, not within 7 to 10 days.
C. "You should give your child captopril 200 mg PO daily." is incorrect. Captopril is not a standard medication used in the treatment of Wilms' tumor. Treatment often involves surgery, chemotherapy, and sometimes radiation therapy.
D. "Your child will not require further treatment after removal of the tumor." is incorrect. Post-surgical treatment, such as chemotherapy and/or radiation therapy, is often required, depending on the stage and extent of the tumor.
Correct Answer is A
Explanation
A. Place a pillow under the child's head: This is correct. The nurse should place a soft object, such as a pillow or folded blanket, under the child’s head to prevent head injury during a seizure. It is important to protect the patient from harm without interfering with the seizure.
B. Turn the child onto their back: This is not advisable during a seizure. The child should remain in a safe position, preferably on their side to help maintain the airway and prevent aspiration. Turning onto their back is not a first-line intervention.
C. Place a padded tongue blade in the child's mouth: This is incorrect. A padded tongue blade should never be inserted into the mouth during a seizure, as it can cause dental or oral injury, and may lead to aspiration or choking.
D. Restrain the child's upper extremities: Restraining the child is not recommended during a seizure. The child should not be physically restrained during the event, as this could cause injury or increase the risk of aspiration. The nurse should focus on providing safety and not interfering with the natural movements during a seizure.
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