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 B

Explanation

A. "Apply rubber-soled slippers before ambulation.": This is important for safety, but it is not the first step in fall prevention. The client needs to be able to call for assistance if needed before moving around.

B. "Determine the client's ability to use the call light.": This should be the first step. Ensuring that the client can easily use the call light in case they need help is a foundational fall prevention strategy. It is essential for maintaining the client’s safety and enabling them to request assistance when needed.

C. "Create a schedule with an assistive personnel to do hourly rounding for the client.": Hourly rounding is an important fall prevention measure, but it should follow initial steps such as ensuring the client can call for help. It can be implemented after determining how the client will communicate needs.

D. "Move the bedside table with the client's personal items close to the bed.": This is a helpful precaution, as it reduces the need for the client to reach or stand to access their belongings. However, the most critical initial step is ensuring the client can safely summon help if needed.

A. Neck is in a flexed position B. Asymmetry of gluteal folds C. Feet turn inward D. Frenulum connected to the tip of the tongue

Correct Answer is A

Explanation

A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.

B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.

C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.

D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.

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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 assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following fall precautions should the nurse plan to implement first?

Correct Answer is B

Explanation

A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?

Correct Answer is A

Explanation

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