At change of shift, the off going nurse notices a distinct odor of alcohol on the breath of the nurse who is receiving report. Which action is most appropriate?

Discuss the situation with another colleague and formulate a plan.

Ask the impaired nurse to go home, or the incident will be reported to the manager.

Immediately inform the charge nurse or the nurse manager of the nurse's breath odor.

Research the state's peer assistance program and discuss the program with the nurse.

Answer and Explanation

The Correct Answer is C

A. Discuss the situation with another colleague and formulate a plan: While discussing the situation with a colleague and formulating a plan may seem like a reasonable approach, it may not address the immediate concern of potential impairment. Delays in reporting could result in the impaired nurse continuing to work, posing a risk to patient safety. Therefore, this option is not the most appropriate action in this scenario.

B. Ask the impaired nurse to go home, or the incident will be reported to the manager: While it may be necessary for the impaired nurse to leave work if they are unfit to practice safely, this action should be taken after informing the appropriate authority figures. Additionally, threatening to report the incident to the manager without following through on informing them immediately may not effectively address the issue. Therefore, this option is not the most appropriate action in this scenario.

C. Immediately inform the charge nurse or the nurse manager of the nurse's breath odor: This is the most appropriate action in this scenario. If a nurse suspects that a colleague may be impaired, it is crucial to report it immediately to the charge nurse or nurse manager. Prompt reporting allows for timely intervention to ensure patient safety and address the nurse's well-being. The charge nurse or nurse manager can then take appropriate steps, such as conducting an assessment, intervening as necessary, and following institutional policies and procedures for addressing impairment.

D. Research the state's peer assistance program and discuss the program with the nurse: While peer assistance programs can be valuable resources for nurses experiencing impairment, they are not the most immediate or appropriate action in this scenario. Addressing the issue of potential impairment requires timely reporting to the charge nurse or nurse manager to ensure patient safety and provide support for the impaired nurse. Therefore, this option is not the most appropriate action in this scenario.

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Correct Answer is ["B","E"]

Explanation

A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.

B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.

C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.

D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.

E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.

A. Spinach B. Potatoes C. Tomatoes D. White rice E. Avocados

Correct Answer is ["A","B","C","E"]

Explanation

A. Spinach: Spinach is an excellent source of potassium. It is a leafy green vegetable that provides a significant amount of potassium, making it a suitable choice for clients who are at risk of potassium loss due to diuretic therapy.

B. Potatoes: Potatoes, particularly when eaten with the skin, are rich in potassium. They are a starchy vegetable that can help replenish potassium levels in individuals experiencing potassium loss from diuretic use.

C. Tomatoes: Tomatoes are another good source of potassium. They are versatile and can be incorporated into various dishes, providing both flavor and nutrients, including potassium, which can help offset potassium depletion caused by diuretics.

D. White rice: White rice is not a significant source of potassium compared to other options listed. While it is a carbohydrate-rich food, it does not contain as much potassium as foods like spinach, potatoes, tomatoes, or avocados.

E. Avocados: Avocados are rich in potassium and are considered a nutrient-dense food. They provide healthy fats along with potassium, making them a beneficial choice for individuals who need to replenish potassium levels depleted by diuretics.

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At change of shift, the off going nurse notices a distinct odor of alcohol on the breath of the nurse who is receiving report. Which action is most appropriate?

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Correct Answer is ["B","E"]

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Correct Answer is ["A","B","C","E"]

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