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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Urine specific gravity should not be reported by the nurse. While urine specific gravity is an important indicator of hydration status and kidney function, the provided information does not suggest any abnormalities in urinary output or signs of kidney issues. It is not the most critical finding to report in this scenario.
Choice B reason:
Prealbumin should not be reported by the nurse. Prealbumin is a protein used to assess nutritional status, but its significance in this situation is not apparent from the provided data. It may be relevant in other contexts, such as assessing malnutrition, but it does not directly address the current findings.
Choice C reason:
Temperature should not be reported by the nurse. The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. While temperature is an important vital sign, it is not relevant to the findings presented in this scenario.
Choice D reason
The nurse should report the "hypoactive bowel sounds upon auscultation" to the provider. Hypoactive bowel sounds can be a sign of gastrointestinal (GI) motility issues, which may indicate a potential problem with the client's digestive system. It could be due to various causes such as bowel obstruction, inflammation, or other GI disorders. Reporting this finding to the provider is essential so that appropriate assessments and interventions can be taken to address the client's condition.
Correct Answer is B
Explanation
Explanation: The nurse should respect and support the client's decision to stop dialysis treatment, as it is an expression of autonomy and self-determination. Discussing alternative treatment methods, asking the facility chaplain to visit, and telling the client she should discuss this decision with her family are all actions that may imply that the nurse does not accept or respect the client's decision.
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