A nurse is observing a newly licensed nurse care for a client who is at increased risk for infection. Which of the following actions indicate the newly licensed nurse is following recommended medical asepsis practices?
The newly licensed nurse uses a paper towel to turn off the faucet after washing their hands.
The newly licensed nurse uses an alcohol-based hand rub and begins patient care before their hands dry.
The newly licensed nurse uses soap and cold water to wash their hands.
The newly licensed nurse uses an alcohol-based hand rub to clean visibly soiled hands.
The Correct Answer is A
A. This action prevents recontamination of the hands after handwashing, which is an essential component of maintaining medical asepsis.
B. It is recommended to allow alcohol-based hand rub to dry completely before engaging in patient care to ensure effectiveness.
C. While handwashing with soap and water is appropriate, cold water may not be as effective as warm water for removing contaminants.
D. Alcohol-based hand rubs are not sufficient for cleaning visibly soiled hands; soap and water are required in such cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.
B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.
However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.
Correct Answer is C
Explanation
A. Using the room number to identify a patient is not reliable since many clients may share it.
B. The telephone number is not typically used for client identification during assessments.
C. The nurse should use the client's name to properly identify the client before performing any assessment or intervention. This is a standard safety measure that helps to prevent errors and ensure quality care.
D. The diagnosis is important for providing appropriate care but is not used for client identification during assessments.
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