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?

Assign clients to the remaining staff.

Document objective findings about the situation.

Remove the nurse from the client care area.

Call the supervisor to ask for another nurse.

Answer and Explanation

The Correct Answer is C

Explanation:

When a charge nurse observes the smell of alcohol on a nurse's breath, it raises concerns about their ability to provide safe and competent care to clients. Patient safety is of utmost importance, and the charge nurse must take immediate action to address the situation.

Removing the nurse from the client care area ensures that the nurse is not involved in direct patient care while their ability to provide safe care is in question. This step helps mitigate potential risks to patient safety.

B and D- After removing the nurse from the client care area, further actions can be taken, such as documenting the objective findings about the situation and informing the supervisor. However, the immediate priority is to ensure patient safety by removing the nurse from the care area.

A- Assigning clients to the remaining staff can be done once the situation has been addressed and a suitable replacement for the nurse has been arranged.

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Correct Answer is ["C"]

Explanation

A.While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.

B. The client received the prescribed antibiotic every 8 hours: This is important information, but it is typically documented in the medication administration record (MAR) and does not need to be included in the verbal report unless there were issues or changes related to the medication.

C. The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

D. The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

A. Locks the wheels on the client's bed B. Clears furniture from the path leading to the bathroom C. Assists the client to the bathroom every 2 hr D. Raises all four side-rails on the client's bed

Correct Answer is D

Explanation

The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.

Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.

Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.

Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.

It's important to promote mobility and independence for the client while ensuring their safety.

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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?