A nurse is assisting with staff education about hand hygiene.
Which of the following instructions should the nurse include in the teaching?
Wear sterile gloves when in contact with body fluids.
Use alcohol-based cleanser when hands are visibly soiled.
Artificial nails can be worn when performing direct client care.
Wash hands with soap and water for 20 seconds.
The Correct Answer is D
Explanation
D, Wash hands with soap and water for 20 seconds
Hand hygiene is a critical practice in preventing the transmission of infections in healthcare settings. Here's why the other options are incorrect:
Wearing sterile gloves when in contact with body fluids in (option A) is incorrect because it is important for preventing the transmission of pathogens, but it is not directly related to hand hygiene. Hand hygiene refers to the cleaning of hands to remove pathogens, and sterile gloves provide a barrier to protect the healthcare worker and the patient.
B. Using an alcohol-based cleanser when hands are visibly soiled in (option B) is not recommended. Alcohol-based cleansers are effective in killing many types of germs, but they are not as effective in removing visible dirt, blood, or body fluids. In such cases, it is important to wash hands with soap and water to thoroughly clean them.
Artificial nails should not be worn when performing direct client care in (option C). They can harbor and transmit pathogens and make it more difficult to effectively clean hands. The Centres for Disease Control and Prevention (CDC) recommends that healthcare workers maintain short, clean, and natural nails without the use of artificial nails or nail extensions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hair loss is a common side effect of chemotherapy, and it can have a significant impact on the client's self-esteem and body image. The nurse should respond with empathy and provide supportive information and resources to help the client cope with hair loss.
Offering head-covering options such as wigs, scarves, or hats can help the client feel more comfortable and confident during the hair loss process.
The other responses are less appropriate:
- "I can't imagine how difficult it would be to lose my hair." While expressing empathy is important, it is crucial to focus on the client's needs and experiences rather than the nurse's own feelings. This response may unintentionally minimize the client's concerns.
- "I wouldn't worry about this right now. Let's focus on your chemotherapy." Dismissing or minimizing the client's concerns about hair loss can be invalidating and may not address the emotional impact it can have on the client. It is important to provide information and support regarding hair loss management as part of comprehensive care.
- "Let's discuss this when we have more time." This response delays addressing the client's concerns and may leave the client feeling unheard or dismissed. The nurse should make an effort to provide support and information in a timely manner to address the client's needs.
Correct Answer is A
Explanation
Explanation
A. Chadwick’s sign
Chadwick's sign is a characteristic change that occurs during pregnancy, specifically in the cervix, vagina, and vulva. It is characterized by a bluish or purplish discoloration of these areas.
Chloasma in (option B) is incorrect because it is a condition characterized by the development of dark patches on the skin, commonly referred to as "mask of pregnancy." Chloasma typically affects the face, particularly the cheeks, forehead, and upper lip. It is not associated with a change in colour in the vaginal or vulvar area.
Hegar's sign in (option C) is incorrect because it is a softening of the lower uterine segment that can be felt during a pelvic examination. It is not related to the colour changes in the vaginal or vulvar area.
Ballottement in (option D) is incorrect because it is a palpation technique used during a prenatal examination to assess the position of the foetus. It involves the examiner gently pushing against the uterus and feeling a rebound or "floating" movement of the foetus. It does not involve changes in the colour of the vaginal or vulvar area.
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