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 B

Explanation

The correct answer is choice B. Removing the client's dentures.

Choice A rationale:

Gathering the client's personal belongings is an appropriate action in the postmortem care process. This step allows the family to receive their loved one's belongings, contributing to a compassionate and respectful care process.

Choice B rationale:

Removing the client's dentures requires intervention by the nurse. In postmortem care, dentures should be left in place to maintain the natural appearance of the deceased's face and to ensure that the mouth and lips maintain their proper form.

Choice C rationale:

Placing absorbent pads under the client's buttocks is a common practice to manage any potential leakage of bodily fluids after death. This action helps maintain the cleanliness and dignity of the deceased individual.

Choice D rationale:

Closing the client's eyes is an appropriate action during postmortem care. It provides a peaceful appearance and shows respect for the deceased person.

A. "What types of foods have you been eating?” B. "Are you using stool softeners or laxatives?” C. "Have you been passing gas?” D. "Have you had small liquid stools?”

Correct Answer is D

Explanation

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

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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 and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is B

Explanation

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Correct Answer is D

Explanation

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence?

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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?

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