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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Evaluating the client for signs of infection is an important nursing action in post-procedure care, but it is not the priority immediately following an amniotomy. The primary concern after an amniotomy is fetal well-being, so monitoring the fetal heart rate is the priority.

Choice B rationale:

Checking the fetal heart rate pattern is the priority nursing action following an amniotomy. Amniotomy involves breaking the amniotic sac, which can potentially lead to changes in the fetal heart rate. Monitoring the fetal heart rate helps assess the baby's well-being and detects any signs of fetal distress.

Choice C rationale:

Observing the color and consistency of amniotic fluid is important for assessing the fluid for signs of meconium staining or infection, but it is not the immediate priority after an amniotomy. Checking the fetal heart rate takes precedence.

Choice D rationale:

Taking the client's temperature is an important part of assessing for infection or fever, but it is not the immediate priority following an amniotomy. Fetal well-being and monitoring are the primary concerns in the immediate post-amniotomy period.

A. Elevated blood pressure. B. Clammy skin. C. Fruity breath odor. D. Bounding pulse.

Correct Answer is C

Explanation

Choice A rationale:

Elevated blood pressure is not typically associated with diabetic ketoacidosis (DKA) In fact, individuals with DKA often experience low blood pressure due to dehydration.

Choice B rationale:

Clammy skin can occur in DKA due to dehydration and metabolic disturbances, but it is not a specific finding that differentiates DKA from other conditions.

Choice D rationale:

A bounding pulse is not a characteristic finding in DKA. Individuals with DKA may have a rapid pulse due to the stress on the body, but it is not typically described as bounding.

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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?

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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?