A nurse observes another nurse frequently removing narcotics from a client's medication drawer and disappearing several times throughout a shift. Which of the following actions should the nurse take?
Ask the client if she is receiving her pain medication.
Assume care of the nurse's clients.
Report the nurse's behavior to a charge nurse.
Confront the nurse about the situation.
The Correct Answer is C
Rationale:
A. Ask the client if she is receiving her pain medication: While assessing the client’s experience with pain management is appropriate, this step does not directly address the suspicious behavior or fulfill the nurse’s professional obligation to report potential substance misuse.
B. Assume care of the nurse's clients: Taking over client care without reporting the issue does not resolve the potential safety concern. It also may be outside the observing nurse’s authority or capacity, and it avoids confronting the root problem.
C. Report the nurse's behavior to a charge nurse: Reporting the observed behavior to a supervisor is the appropriate first action. It allows the situation to be formally investigated and ensures that client safety and professional accountability are maintained.
D. Confront the nurse about the situation: Confronting a colleague suspected of substance misuse can escalate the situation and may be unsafe. It bypasses institutional reporting protocols and may place the observing nurse at risk personally or professionally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Adjust the heparin dosage based on the client's PT level: PT (prothrombin time) monitors warfarin, not heparin. Heparin dosing is adjusted based on the aPTT, which reflects the intrinsic clotting pathway affected by heparin.
B. Wrap the affected area with cool, moist packs intermittently during the day: Cold packs cause vasoconstriction and are not recommended for clients with DVT. They can potentially increase discomfort and impair circulation in the already compromised limb.
C. Administer vitamin K via IM injection for heparin toxicity: Vitamin K is the reversal agent for warfarin toxicity. Heparin toxicity is treated with protamine sulfate, which neutralizes its anticoagulant effects.
D. Apply thigh-high, sequential compression stockings to the client's legs: Applying thigh-high, sequential compression stockings to the client's legs is a suitable action to promote venous return and prevent blood clots. Compression stockings are commonly used in patients at risk of deep-vein thrombosis.
Correct Answer is C
Explanation
Rationale:
A. Unreasonable intrusion: This term refers to a violation of a client's right to privacy, such as entering a room without consent or exposing private health information. It does not apply to patient injury or safety issues resulting from care decisions.
B. Libel: Libel involves written defamation that harms a person’s reputation. It is not relevant to a situation involving physical injury or improper use of restraints like raised bedrails.
C. Negligence: Negligence occurs when a nurse fails to provide the standard of care, leading to client harm. Raising all four side rails can be considered a form of restraint and increases the risk of injury from falls, especially if the client attempts to climb over them, making this a clear example of negligence.
D. Assault: Assault in nursing involves threatening or attempting to touch a client without consent. It does not apply to passive actions that result in harm, such as improper restraint or fall risk management.
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