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","C","D"]

Explanation

A. Jugular vein distention: Jugular vein distention is not typically associated with deficient fluid volume (dehydration). Instead, it is often seen in conditions of fluid overload, such as heart failure or volume overload. Therefore, this finding is not accurate for deficient fluid volume.

B. Skin turgor, tenting at clavicular area: Skin turgor refers to the skin's ability to return to its normal position after being pinched or pulled. In cases of deficient fluid volume (dehydration), skin turgor is decreased, leading to delayed return of the skin to its normal state. Tenting at the clavicular area is a specific sign of decreased skin turgor and is indicative of dehydration.

C. Elevated hematocrit: Deficient fluid volume (dehydration) leads to hemoconcentration, where there is a relative increase in the proportion of red blood cells to plasma volume. As a result, the hematocrit level, which represents the percentage of red blood cells in the total blood volume, increases. An elevated hematocrit is a laboratory finding commonly associated with deficient fluid volume.

D. Oral mucous membranes dry and sticky: Dehydration can lead to decreased saliva production and dryness of the oral mucous membranes. Dry and sticky oral mucous membranes are common clinical signs of deficient fluid volume (dehydration) and indicate inadequate fluid intake or loss.

A. Type of diet B. Cultural considerations C. Gender D. History of onset

Correct Answer is D

Explanation

A. Type of diet: While the type of diet may be relevant to the overall health and well-being of the older adult client, it may not directly contribute to understanding the change in mental status. While nutritional deficiencies or imbalances could potentially impact mental status, other factors are more immediately relevant to assessing the change in mental status.

B. Cultural considerations: Cultural considerations are important in providing holistic care to the older adult client, but they may not directly contribute to understanding the change in mental status. Cultural factors could influence communication styles, beliefs about health and illness, and preferences for care, but they may not be the primary focus when assessing a change in mental status.

C. Gender: Gender may have some relevance to the overall health and well-being of the older adult client, but it may not directly contribute to understanding the change in mental status. While certain gender-related factors, such as hormonal changes or gender-specific health conditions, could potentially impact mental health, they may not be the primary focus when assessing a change in mental status.

D. History of onset: This represents a critical thinking approach because understanding the history of onset of the change in mental status is essential for identifying potential causes and determining appropriate interventions. The timing and circumstances surrounding the onset of the change can provide valuable information about possible contributing factors, such as recent illnesses, medication changes, trauma, or environmental changes. By gathering information about the history of onset, the nurse can engage in critical thinking to formulate hypotheses, prioritize assessments, and develop a plan of care tailored to the client's needs.

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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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Naxlex Comprehensive Predictor Exams

The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

Correct Answer is ["B","C","D"]

Explanation

An older adult client experiences a change in mental status. Which assessment finding represents a critical thinking approach?

Correct Answer is D

Explanation

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