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.
Document objective findings about the situation.
Remove the nurse from the client care area.
Assign clients to the remaining staff.
The Correct Answer is C
Choice A rationale:
Calling the supervisor to ask for another nurse is not the first action the charge nurse should take when noticing the smell of alcohol on a nurse's breath. While it's important to involve the supervisor, immediate action to ensure patient safety is required.
Choice B rationale:
Documenting objective findings about the situation is a valid step in the process, but it should not be the first action. The charge nurse's primary responsibility is to address the immediate safety concerns.
Choice C rationale:
Removing the nurse from the client care area is the first action the charge nurse should take when smelling alcohol on a nurse's breath. This action ensures patient safety and prevents potential harm caused by impaired nursing care.
Choice D rationale:
Assigning clients to the remaining staff is not the first action to take when there is suspicion of alcohol impairment in a nurse. Patient safety and addressing the situation involving the impaired nurse take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.
Choice B rationale:
An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.
Choice C rationale:
Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.
Choice D rationale:
Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.
Correct Answer is D
Explanation
Choice A rationale:
Replace the IV pump's tubing. Replacing the IV pump's tubing is not the appropriate action when the IV pump screen is malfunctioning. Malfunctioning tubing does not typically affect the pump's screen or settings.
Choice B rationale:
Clear the settings and reset the IV pump. Clearing the settings and resetting the IV pump may not be effective if the screen is malfunctioning. It is important to ensure the accuracy and safety of IV fluid administration, and troubleshooting the screen is not a reliable solution in the case of a malfunction.
Choice C rationale:
Plug the IV pump's cord into a different outlet. Changing the outlet may help if the issue is related to electrical power, but it is not the most appropriate action when the IV pump screen is malfunctioning. Safety concerns and potential equipment issues warrant discontinuing use and tagging the pump.
Choice D rationale:
Discontinue use and tag the IV pump. When the IV pump screen is malfunctioning, the safest and most appropriate action is to discontinue its use and tag the pump. This ensures that the malfunctioning equipment is not used on other patients and that a thorough inspection and repair can be conducted to prevent potential harm to the patient.
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