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.
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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Related Questions
Correct Answer is C
Explanation
Informed consent is a legal and ethical requirement for certain medical procedures. It involves providing the client with clear and comprehensive information about the procedure, including its risks, benefits, alternatives, and expected outcomes. The client must understand the information provided and voluntarily give their consent before the procedure can be performed.
Placement of a central venous catheter is an invasive procedure that carries risks and potential complications, making it necessary to obtain informed consent from the client.
Wound irrigation with an antibiotic solution is a standard nursing intervention for wound care and does not usually involve invasive procedures. Informed consent is not typically required for this procedure.
The administration of an iron injection using the Z-track technique is a standard nursing procedure. While it involves an injection, it is not typically considered an invasive procedure that would require informed consent.
Insertion of a nasogastric tube is a common procedure that involves passing a tube through the nose and into the stomach for various purposes, such as feeding, decompression, or medication administration. While it is an invasive procedure, it is often performed in emergency or critical care situations where the client's immediate well-being takes precedence. Informed consent may not be feasible or necessary in these situations, depending on the context and urgency.
Correct Answer is ["A","B","C","E","G"]
Explanation
Based on the given information, the nurse should take the following actions in preparation for surgery:
- Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
- Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
- Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
- Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
- Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.
The following actions are not indicated based on the given information:
- Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
- Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.
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