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. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

A. Clean the client's skin with soap and hot water. B. Limit the client's fluid intake. C. Use a moisture barrier on the client's skin. D. Massage the area around the client's coccyx.

Correct Answer is C

Explanation

A. "Clean the client's skin with soap and hot water" is incorrect. Soap and hot water can be harsh on the skin and can cause irritation, especially in clients who are at risk for skin breakdown. The nurse should use lukewarm water and a gentle cleanser to clean the skin.

B. "Limit the client's fluid intake" is incorrect. Limiting fluid intake is not a recommended approach for preventing skin breakdown. Proper hydration helps maintain skin elasticity and prevent dryness.

C. "Use a moisture barrier on the client's skin" is correct. A moisture barrier is crucial for protecting the skin from prolonged exposure to moisture from incontinence, which can lead to skin breakdown. The barrier helps prevent irritation and allows the skin to stay intact.

D. "Massage the area around the client's coccyx" is incorrect. Massaging over bony prominences, such as the coccyx, is not recommended, as it can damage tissue and increase the risk of pressure ulcers. The nurse should avoid massaging these areas.

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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 reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown?

Correct Answer is C

Explanation

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