A nurse is assisting with staff education about hand hygiene.
Which of the following instructions should the nurse include in the teaching?
Wash hands with soap and water for 20 seconds.
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.
The Correct Answer is A
Choice A rationale:
The nurse should include the instruction to wash hands with soap and water for 20 seconds in the teaching. This is a fundamental aspect of hand hygiene in healthcare settings. The rationale for this choice is that proper handwashing with soap and water for at least 20 seconds is the most effective way to remove dirt, debris, and transient microorganisms from the hands. It helps prevent the spread of infections, including those caused by viruses and bacteria.
Choice B rationale:
Wearing sterile gloves when in contact with body fluids is not directly related to hand hygiene education. While wearing gloves is an essential infection control practice, it is not a substitute for proper handwashing. Hand hygiene should be performed before donning gloves and after removing them.
Choice C rationale:
Using alcohol-based cleanser when hands are visibly soiled is not the best instruction for hand hygiene. Alcohol-based hand sanitizers are effective when hands are not visibly soiled. In cases of visible soiling, handwashing with soap and water is recommended to physically remove dirt and contaminants.
Choice D rationale:
Artificial nails should not be worn when performing direct client care as they can harbor microorganisms and make it challenging to clean the hands adequately. The use of artificial nails can increase the risk of transmitting infections to patients, which is why they should be discouraged in healthcare settings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Temperature of 39°C (102.2°F) A temperature of 39°C (102.2°F) is elevated, but it is not directly related to a heart rate of 44/min. Elevated temperature can be caused by various factors, such as infection, and would not be an expected finding solely due to the heart rate.
Choice B rationale:
History of cigarette smoking. A history of cigarette smoking may be a risk factor for certain cardiovascular conditions, but it does not directly explain a heart rate of 44/min. The heart rate can be influenced by factors such as medications, cardiac conditions, and autonomic nervous system activity.
Choice D rationale:
Hypoglycemia. Hypoglycemia (low blood sugar) can cause various symptoms, including shakiness, confusion, and sweating, but it is not the primary cause of a heart rate of 44/min. Hypoglycemia is more likely to cause symptoms related to altered mental status and autonomic nervous system activation.
Choice C rationale:
Patient reports they feel that they are going to pass out. A heart rate of 44/min is significantly lower than the normal range for adults, which is typically between 60-100 beats per minute. Such a low heart rate, known as bradycardia, can lead to decreased blood flow to vital organs, including the brain. Feeling like they are going to pass out is a concerning symptom associated with bradycardia because it suggests inadequate cardiac output and perfusion. This finding should prompt immediate assessment and intervention to address the underlying cause of the slow heart rate.
Correct Answer is D
Explanation
The Heelis not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The coccyx, or tailbone, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
The Occiput, is not in direct contact with the bed surface when a client is in the prone position. Therefore, a pillow is not typically needed to relieve pressure in this area.
he breasts, particularly in female clients, can experience significant pressure when in the prone position. Using a small pillow can help to relieve this pressure and increase the client’s comfort.A small pillow can help support the client’s breasts and prevent them from being compressed or injured during the prone position1.The breasts are a sensitive area that can be affected by gravity, friction, or pressure2.A pillow can also help maintain proper body alignment and prevent hyperextension of the back
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