A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Rub hands and arms to dry.

Adjust the water temperature to feel hot.

Apply 4 to 5 mL of liquid soap to the hands.

Hold the hands higher than the elbows.

Answer and Explanation

The Correct Answer is C

A.   Rubbing hands and arms to dry is not the correct action for hand hygiene. After applying soap, hands should be rinsed thoroughly with water and then dried using a clean towel or air dryer.
B.   Adjusting the water temperature to feel hot is not recommended for hand hygiene.
Water that is too hot can be uncomfortable and may even cause skin irritation. The water should be comfortably warm.
C.   Applying 4 to 5 mL of liquid soap to the hands is the correct action. This provides an adequate amount of soap to create a good lather for effective handwashing.
D.   Holding the hands higher than the elbows is not a necessary step for hand hygiene.
The focus should be on thoroughly cleaning the hands, not on the position of the hands in relation to the elbows.

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Correct Answer is A

Explanation

A. The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.

A. Hold the container of solution 30 cm (12 in) above the anus. B. Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus. C. Hold the container of solution level with the client's upper hip. D. Keep the container of solution at a level to maintain client comfort.

Correct Answer is A

Explanation

A. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

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