A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?

Rub soap on hands for 20 seconds.

Allow hands and arms to dry.

Hold the hands higher than the elbows.

Adjust the water temperature to feel hot.

Answer and Explanation

The Correct Answer is A

Effective hand hygiene is crucial in preventing the spread of infections in healthcare settings. The Centers for Disease Control and Prevention (CDC) and other health organizations provide guidelines on proper hand hygiene techniques to ensure maximum effectiveness.

Choice A Reason:

“Rub soap on hands for 20 seconds.”

This is the correct action for effective hand hygiene. According to the CDC, scrubbing your hands for at least 20 seconds is essential to remove germs effectively. This duration ensures that all surfaces of the hands, including the backs, between the fingers, and under the nails, are thoroughly cleaned. The CDC recommends singing the “Happy Birthday” song twice as a timer to ensure you scrub for the full 20 seconds.

Choice B Reason:

“Allow hands and arms to dry.”

While drying hands is an important step in hand hygiene, it is not the primary action that makes hand hygiene effective. The focus should be on the thorough scrubbing and cleaning of the hands. After washing, hands should be dried using a clean towel or air dryer to prevent the transfer of germs from wet hands.

Choice C Reason:

“Hold the hands higher than the elbows.”

This technique is often used in surgical hand antisepsis to prevent water from running from the hands down to the elbows, potentially contaminating the hands again. However, for routine hand hygiene, this is not necessary. The primary focus should be on the thorough washing and scrubbing of the hands.

Choice D Reason:

“Adjust the water temperature to feel hot.”

The temperature of the water is less important than the act of scrubbing itself. The CDC states that hands can be washed with either warm or cold water. The key is to use soap and scrub all surfaces of the hands for at least 20 seconds. Hot water can actually be harsh on the skin and is not required for effective hand hygiene.

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Correct Answer is A

Explanation

Choice A Reason:

Metabolic Alkalosis is correct. The pH of 7.56 is above the normal range (7.35-7.45), indicating alkalosis. The HCO3 level of 33 mEq/L is also above the normal range (22-28 mEq/L), which suggests a metabolic cause. In metabolic alkalosis, the body has an excess of bicarbonate or a loss of hydrogen ions.

Choice B Reason:

Metabolic Acidosis is incorrect. Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO3 level (below 22 mEq/L). The given values indicate alkalosis, not acidosis.

Choice C Reason:

Respiratory Alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH (above 7.45) and a low PaCO2 (below 35 mmHg). In this case, the PaCO2 is elevated (55 mmHg), which does not align with respiratory alkalosis.

Choice D Reason:

Respiratory Acidosis is incorrect. Respiratory acidosis is characterized by a low pH (below 7.35) and a high PaCO2 (above 45 mmHg). While the PaCO2 is elevated, the pH indicates alkalosis, not acidosis.

A. Repeat auscultation after asking the client to take a deep breath and cough. B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. Place the client on bed rest in semi-Fowler’s position. D. Prepare to administer antibiotics.

Correct Answer is A

Explanation

Choice A Reason:

Repeating auscultation after asking the client to take a deep breath and cough is the first intervention the nurse should take. This action helps to clear any secretions or mucus that might be causing the crackles. If the crackles persist after the client coughs, it indicates that the sounds are likely due to fluid in the lungs, which requires further assessment and intervention. This step ensures that the nurse accurately identifies the cause of the crackles before proceeding with other interventions.

Choice B Reason:

Instructing the client to limit fluid intake to less than 2,000 mL/day might be appropriate in cases of fluid overload or heart failure, but it is not the first intervention. The nurse needs to confirm the cause of the crackles before making any recommendations about fluid intake. Limiting fluid intake without proper assessment could lead to dehydration and other complications.

Choice C Reason:

Placing the client on bed rest in semi-Fowler’s position can help improve lung expansion and oxygenation by reducing pressure on the diaphragm. However, this is not the first intervention. The nurse should first determine if the crackles are due to secretions that can be cleared by coughing. Semi-Fowler’s position is beneficial for patients with respiratory distress, but it does not address the immediate need to reassess lung sounds.

Choice D Reason:

Preparing to administer antibiotics is not the first intervention. Antibiotics are used to treat infections, and the nurse needs to confirm whether the crackles are due to an infection or another cause before administering medication. Immediate administration of antibiotics without proper assessment could lead to inappropriate treatment and antibiotic resistance.

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A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances? The values are: pH: 7.56 PaCO2: 55 mmHg HCO3: 33 mEq/L Normal ranges: pH: 7.35-7.45 PaCO2: 35-45 mmHg HCO3: 22-28 mEq/L

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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