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 B
Explanation
Choice A rationale:
Injecting additional insulin before exercising is not a recommended practice for individuals with type 1 diabetes mellitus. It can lead to hypoglycemia (low blood sugar) during exercise. The goal is to ensure that blood glucose levels are within a safe range before starting physical activity.
Choice B rationale:
Eating a piece of fruit before exercising is a suitable recommendation for someone with type 1 diabetes mellitus. Consuming a source of carbohydrates, such as fruit, can help prevent hypoglycemia during exercise. Carbohydrates provide a steady source of glucose for energy.
Choice C rationale:
Exercising when insulin is at its peak action can be risky for individuals with type 1 diabetes. At this time, the risk of hypoglycemia is higher because insulin is actively lowering blood sugar levels. It is generally recommended to exercise when insulin is at a moderate or lower level of activity to reduce the risk of hypoglycemia.
Choice D rationale:
Avoiding protein before exercising is not a specific recommendation for individuals with type 1 diabetes mellitus. While protein does not directly impact blood glucose levels as carbohydrates do, it is an essential nutrient for overall health. A balanced meal or snack that includes carbohydrates and protein is typically a better choice before exercise.
Correct Answer is C
Explanation
Choice A rationale:
Massaging the affected extremity is contraindicated in a client with deep-vein thrombosis (DVT) Massaging the area can dislodge the blood clot, leading to embolism and potentially life-threatening complications.
Choice B rationale:
Administering aspirin for pain is not the appropriate action for a client with deep-vein thrombosis. Aspirin is not the primary treatment for DVT, and it does not address the underlying cause or prevent further clot formation.
Choice C rationale:
Initiating bed rest is the correct action for a client with deep-vein thrombosis. Bed rest helps to reduce the risk of clot dislodgement and embolism. The client should avoid unnecessary movement and keep the affected leg elevated to promote blood flow and prevent complications.
Choice D rationale:
Applying an ice pack to the affected extremity is not the recommended intervention for a client with deep-vein thrombosis. Cold application can cause vasoconstriction, potentially worsening the condition by reducing blood flow to the already affected area.
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