The practical nurse (PN) is preparing to provide a change of shift report when an oncoming nurse arrives, appearing intoxicated, and who describes to another colleague about drinking all afternoon and almost forgetting to come to work. Which action should the PN take first?
Notify the nursing board.
Submit an incident report.
Email the nurse manager.
Inform the charge nurse.
The Correct Answer is D
A. Notify the nursing board: Reporting to the nursing board is necessary for ongoing professional accountability but is not the immediate first step. The priority is to ensure the safety of clients by addressing the situation within the facility first.
B. Submit an incident report: An incident report documents the event, but it should be completed after immediate concerns for client safety are addressed. It is not the first action when dealing with an impaired nurse.
C. Email the nurse manager: Emailing the nurse manager may delay the response. Immediate verbal communication with someone in a supervisory role is essential to remove the impaired nurse from client care duties without delay.
D. Inform the charge nurse: Informing the charge nurse immediately is the priority because the charge nurse has the authority to intervene quickly, ensure the impaired nurse is removed from duty, and maintain patient safety. This allows for appropriate administrative steps to follow afterward.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.
Correct Answer is B
Explanation
A. Show the UAP how to use a transfer belt to safely move the client: A transfer belt is useful for clients who can bear some weight and follow instructions. Since the client is confused and cannot bear weight, using a transfer belt is unsafe and increases the risk of injury.
B. Work with the UAP to use a mechanical lift and sling for the transfer: A mechanical lift provides the safest method for transferring a confused, non-weight-bearing client. It minimizes the risk of injury to both the client and staff while ensuring the transfer is done safely and correctly.
C. Instruct the UAP to use a pivot technique when moving the client: Pivot techniques require the client to bear weight and follow simple directions, neither of which is appropriate given the client's confusion and inability to bear weight.
D. Notify the charge nurse that the client cannot be transferred: While updating the charge nurse may eventually be needed, the immediate action is to modify the transfer method to ensure the client's needs are safely met using appropriate equipment.
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