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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Decreased skin turgor. Decreased skin turgor is a sign of dehydration rather than fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms like crackles in the lungs, edema, and increased blood pressure. Decreased skin turgor is more characteristic of dehydration, where the body loses fluid.

Choice B rationale:

Decreased blood pressure. Decreased blood pressure is not typically a manifestation of fluid overload. Fluid overload often leads to increased blood pressure as the heart has to work harder to pump excess fluid throughout the body.

Choice C rationale:

Weight loss. Weight loss is not a manifestation of fluid overload. In fact, fluid overload may lead to weight gain due to the retention of excess fluid in the body.

Choice D rationale:

Crackles heard in the lungs. Crackles heard in the lungs are a common manifestation of fluid overload. When there is an excessive accumulation of fluid in the lungs, it can interfere with the exchange of gases and cause crackling sounds during breathing. This is a significant clinical finding that indicates the need for intervention and assessment of fluid balance.

A. Abdominal cramping B. Weight loss C. Diarrhea D. Anemia

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"}}

Explanation

The data collection findings are consistent with the following disease processes: Abdominal cramping: This finding can indicate ulcerative colitis, diverticulitis, or Crohn’s disease.

Abdominal cramping is a common symptom of inflammation and infection in the digestive tract. Weight loss: This finding can indicate ulcerative colitis or Crohn’s disease. Weight loss can result from malabsorption, reduced appetite, inflammation, or complications of the disease. Diarrhea: This finding can indicate ulcerative colitis or Crohn’s disease. Diarrhea is caused by increased intestinal motility, inflammation, and ulceration of the mucosa. Anemia: This finding can indicate ulcerative colitis or Crohn’s disease. Anemia can result from chronic blood loss, iron deficiency, vitamin B12 deficiency, or inflammation. The finding of fatty appearance and foul odor of the stool is also consistent with Crohn’s disease, as it suggests steatorrhea (excess fat in the stool) due to malabsorption. The finding of a positive fecal occult blood test is consistent with ulcerative colitis or Crohn’s disease, as it indicates bleeding in the digestive tract.

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A nurse is assisting with staff education about hand hygiene.Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client. Exhibits Data Collection Findings. For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,C"},"C":{"answers":"A,C"},"D":{"answers":"A,C"}}

Explanation

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A nurse is assisting with staff education about hand hygiene.
Which of the following instructions should the nurse include in the teaching?