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.

Remove the nurse from the client care area.

Assign clients to the remaining staff.

Document objective findings about the situation.

Answer and Explanation

The Correct Answer is B

Explanation: The first action that the charge nurse should take is to remove the nurse from the client care area, as this will protect the clients from potential harm and prevent further impairment of the nurse. The charge nurse should then call the supervisor, assign clients to other staff members, and document objective findings about the situation.

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Correct Answer is ["B","C","D"]

Explanation

A.Planning care, especially for a client with dysphagia (difficulty swallowing), involves assessment, evaluation, and critical thinking, which are within the scope of practice for licensed nurses, not APs. This task should not be delegated to an AP.

B.Transferring a client, especially one undergoing radiation therapy, often involves understanding specific precautions and handling techniques. This task is generally within the scope of APs, provided they have proper training and understand any specific precautions related to the client's condition.

C.Recording urine output is ataskthat can be delegated to an assistive personnel under the supervision of a registerednurse, as they do not require nursing judgment or assessment skills.

D.Measuring vital signs is a taskthat can be delegated to an assistive personnel under the supervision of a registered nurse, as they do not require nursing judgment or assessment skills.

A. History of ectopic pregnancy B. Vaginal yeast infection C. Hypertension D. Irregular menses

Correct Answer is C

Explanation

The correct answer is C.

Hypertension. The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of

cardiovascular events such as stroke, heart attack or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.

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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 in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?

Correct Answer is C

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

A nurse is reviewing information about ethical client care with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

A nurse is collecting data from a client who reports difficulty sleeping at night. Which of the following client statements indicates an understanding of sleep promotion?

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?