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?

Call the supervisor to ask for another nurse.

Assign clients to the remaining staff.

Document objective findings about the situation.

Remove the nurse from the client care area.

Answer and Explanation

The Correct Answer is D

The presence of alcohol on a nurse's breath raises concerns regarding impairment and the potential for compromised patient safety. It is crucial to prioritize patient safety and prevent any potential harm. Removing the nurse from the client care area ensures that immediate patient safety is addressed and minimizes the risk of any adverse events.

Call the supervisor to ask for another nurse: While involving the supervisor is important, it should not be the first action taken in this situation. The immediate priority is to address patient safety by removing the nurse from the client care area.

Assign clients to the remaining staff: Assigning clients to the remaining staff should not be the first action taken because it may compromise patient safety if the nurse in question is impaired. It is important to ensure that the nurse is removed from the client care area before reassigning the clients to other staff members.

Document objective findings about the situation: Documenting the objective findings about the situation is important for accurate record-keeping and reporting. However, it should not be the first action taken when immediate patient safety is at stake. Removing the nurse from the client care area is the priority.

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Correct Answer is D

Explanation

Answer: D

Rationale:

A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.

B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.

C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.

D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.

A. "You should verify the identity of anyone who wants to remove your baby from the room." B. "You can leave your baby in your room while you walk in the hallway." C. "Your baby should have one identification band on either their right arm or right leg." D. "You can leave the unit with your baby as long as you notify the nurse."

Correct Answer is A

Explanation

The nurse should include the instruction to "verify the identity of anyone who wants to remove your baby from the room" in the teaching about security procedures. It is important for parents to be vigilant and ensure that only authorized personnel have access to their baby.

Option b is incorrect because it may not be safe for the parent to leave their baby unattended in their room while they walk in the hallway.

Option c is incorrect because newborns typically have two identification bands, one on their arm and one on their leg.

Option d is incorrect because parents should not leave the unit with their baby without proper authorization and discharge procedures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a sputum specimen from a client for culture and sensitivity. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with the parent of a newborn about security procedures. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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