A nurse is planning a quality control audit to measure the occurrence of health care-associated infections at an outpatient facility. Which of the following steps should the nurse plan to take first?

Rationale:

A. Increased D-dimer: Clients with systemic lupus erythematosus (SLE) are at increased risk for thromboembolic events due to antiphospholipid antibodies. A D-dimer may be elevated due to ongoing coagulation and fibrinolysis activity, especially during active disease or clot formation.

B. Elevated brain natriuretic peptide: BNP is primarily used to assess heart failure. While pericarditis or myocarditis can occur in SLE, an elevated BNP is not a typical finding unless there is coexisting heart dysfunction.

C. Elevated erythrocyte sedimentation rate: ESR is commonly elevated in SLE due to systemic inflammation. It serves as a nonspecific marker of disease activity and is frequently used to monitor flares or response to therapy.

D. Positive rheumatoid factor: Although most commonly associated with rheumatoid arthritis, RF can also be positive in SLE. It reflects an overlap of autoimmune markers seen in various connective tissue disorders.

E. Elevated troponin I: Troponin I is a marker of myocardial injury. While SLE can involve the heart, elevated troponin I would only be expected in cases of active cardiac involvement, such as myocarditis or infarction, and is not a routine finding in all SLE patients.

Rationale:

A. Confront the nurse with an explanation of performance expectations: The nurse manager has a legal and ethical duty to act immediately when a staff member is suspected of being chemically impaired at work. Confronting the nurse in a private, professional manner protects patient safety and initiates the process of accountability and appropriate referral.

B. Participate in the nurse's recovery process by providing direct care: While supporting the nurse's recovery is important, direct involvement in their care is inappropriate and presents a conflict of interest. The nurse manager should refer the staff nurse to an employee assistance or peer support program instead.

C. Plan to conduct a counseling session with the nurse on the following morning: Delaying action jeopardizes patient safety and violates facility policy. Chemically impaired nurses must be addressed immediately to prevent harm to clients and ensure regulatory compliance.

D. Determine why the nurse is using the chemically-impairing substance: The manager is not responsible for investigating the personal reasons behind substance use. Instead, their responsibility is to intervene appropriately and refer the individual to qualified professionals for assessment and support.