A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

Rinse their forearms with running water before applying soap.

Hold their hands above elbow level while washing and rinsing.

Generate a lather by rubbing their hands together vigorously for 5 seconds.

Turn off the faucet with a clean paper towel after drying hands.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

Rinsing forearms with running water before applying soap is not a recommended step in the handwashing procedure. The primary step is to wet the hands, apply soap, and create a lather.

Choice B rationale:

Holding hands above elbow level while washing and rinsing is not a standard practice for handwashing. The hands should be washed thoroughly, and the focus is on scrubbing the hands, not their positioning.

Choice C rationale:

Generating a lather by rubbing hands together vigorously for 5 seconds is insufficient for effective handwashing. Proper handwashing involves rubbing hands together for at least 20 seconds to ensure thorough cleaning.

Choice D rationale:

The correct answer. After washing and drying hands, turning off the faucet with a clean paper towel is recommended to avoid recontaminating the clean hands. Touching the faucet directly with clean hands could potentially transfer pathogens back onto the hands.

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Correct Answer is A

Explanation

The correct answer is choice A: "Stand with your feet together and your arms at your sides."

Choice A rationale:

This statement is correct. The nurse should instruct the client to stand with their feet together and their arms at their sides for a Romberg test. This position helps to assess the client's ability to maintain balance with minimal sensory input, evaluating their proprioception and vestibular function.

Choice B rationale:

The instruction about the tuning fork is unrelated to the Romberg test. The tuning fork is commonly used to assess hearing and vibratory sensations, not balance.

Choice C rationale:

This statement is unrelated to the Romberg test. Mentioning the lateral side of the foot suggests a neurological examination related to assessing reflexes, such as the Babinski reflex.

Choice D rationale:

This instruction pertains to a different test known as the "finger-to-nose" test, which is used to assess coordination, not balance.

A. Use pictures of different food groups to help the client plan a daily menu. B. Ask the client what they already know about meal planning. C. Give the client a brochure with sample menus for all meals. D. Involve the family in the discussion of the client's meal plan.

Correct Answer is B

Explanation

The correct answer is choice B: Ask the client what they already know about meal planning.

Choice A rationale:

Using pictures of different food groups can be helpful in teaching about carbohydrate counting, but it's important to assess the client's current knowledge and understanding before introducing new information. Starting with this approach might overwhelm the client or duplicate information they already possess.

Choice B rationale:

This is the correct choice. Before providing education, it's crucial to assess the client's baseline knowledge. By asking the client what they already know about meal planning, the nurse can tailor the teaching plan to fill in any gaps and avoid presenting redundant information. This approach respects the client's current understanding and focuses on addressing their specific needs.

Choice C rationale:

Giving the client a brochure with sample menus can be helpful once the nurse has assessed the client's knowledge and educational needs. However, providing the brochure as the first action might not be effective if the client already has some understanding of meal planning or if the brochure does not address the client's specific questions.

Choice D rationale:

Involving the family in the discussion of the client's meal plan is important for long-term support, but it shouldn't be the first action. First, the nurse should ensure that the client's own understanding and preferences are addressed before considering input from family members.

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A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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