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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
The correct answer is choice D. The client has tenderness and warmth in their calf.
Choice A rationale:
The client's self-reported incisional pain level of 7 on a scale of 0 to 10 is important information to assess postoperative recovery, but it is not the priority finding to report among the choices. Pain management is crucial, but potential complications that could be more urgent should be addressed first.
Choice B rationale:
Increased nausea and chills are concerning postoperative findings, but they could be related to the body's response to surgery, anesthesia, or pain medications. While these symptoms should be monitored and managed, they are not as high-priority as potential complications involving the calf.
Choice C rationale:
An oral temperature of 38.5°C (101.3°F) indicates a fever and is also a concerning finding in the postoperative period. Infection could be a possible cause, and the provider should be informed. However, compared to tenderness and warmth in the calf, which could suggest deep vein thrombosis (DVT), the fever is of slightly lower priority.
Choice D rationale:
Tenderness and warmth in the calf are the priority findings to report. These symptoms raise concern about the possibility of deep vein thrombosis (DVT), a serious complication after surgery. DVT occurs when a blood clot forms in a deep vein, commonly in the legs. If left untreated, it can lead to a pulmonary embolism, a life-threatening condition where the clot travels to the lungs. Immediate assessment and intervention are necessary to rule out or address this potentially critical complication.
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