A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

Dry hands thoroughly from fingers to wrist.

Hold the hands slightly higher than the elbows when using running water.

Wash hands under running water for at least 10 seconds.

Clean hands with alcohol-based hand gel for 16 seconds.

Answer and Explanation

The Correct Answer is A

A. Drying hands thoroughly from fingers to wrist is correct. Proper drying technique is important because residual moisture can harbor bacteria, and drying from fingers to wrist prevents recontamination of clean areas by water dripping from contaminated areas.

B. Holding hands slightly higher than the elbows when using running water is incorrect. The proper technique is to hold hands lower than the elbows to allow water to flow downward, preventing recontamination of clean areas by dirty water.

C. Washing hands under running water for at least 10 seconds is incorrect. The recommended duration for effective handwashing is at least 20 seconds with soap and water to ensure the removal of pathogens.

D. Cleaning hands with alcohol-based hand gel for 16 seconds is incorrect. The recommended time for using alcohol-based hand rubs is at least 20 seconds, ensuring thorough coverage of all surfaces for effective pathogen removal.

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Correct Answer is D

Explanation

A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.

B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.

C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.

D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..

A. Preferred bath time B. Time of last pain medication C. Steps required for dressing change D. Admission vital signs

Correct Answer is B

Explanation

A. Preferred bath time is incorrect. While important for comfort and care planning, the preferred bath time is not critical information for change-of-shift report unless directly relevant to immediate care.

B. Time of last pain medication is correct. Information about the last dose of pain medication is essential to assess the client’s current pain level and determine if another dose is required. It also helps to plan for ongoing pain management and monitor for signs of over-medication or under-medication.

C. Steps required for dressing change is incorrect. While it is important to know the steps for dressing changes, this would typically be included in the written care instructions, not necessarily as part of the verbal change-of-shift report.

D. Admission vital signs is incorrect. Admission vital signs are not typically necessary for change-of-shift report unless there has been a significant change in the client’s condition since admission. It is more important to focus on current assessments and interventions.

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A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?

Correct Answer is D

Explanation

A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?

Correct Answer is B

Explanation

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