A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?

Choice A rationale:

The nurse should include the instruction to wash hands with soap and water for 20 seconds in the teaching. This is a fundamental aspect of hand hygiene in healthcare settings. The rationale for this choice is that proper handwashing with soap and water for at least 20 seconds is the most effective way to remove dirt, debris, and transient microorganisms from the hands. It helps prevent the spread of infections, including those caused by viruses and bacteria.

Choice B rationale:

Wearing sterile gloves when in contact with body fluids is not directly related to hand hygiene education. While wearing gloves is an essential infection control practice, it is not a substitute for proper handwashing. Hand hygiene should be performed before donning gloves and after removing them.

Choice C rationale:

Using alcohol-based cleanser when hands are visibly soiled is not the best instruction for hand hygiene. Alcohol-based hand sanitizers are effective when hands are not visibly soiled. In cases of visible soiling, handwashing with soap and water is recommended to physically remove dirt and contaminants.

Choice D rationale:

Artificial nails should not be worn when performing direct client care as they can harbor microorganisms and make it challenging to clean the hands adequately. The use of artificial nails can increase the risk of transmitting infections to patients, which is why they should be discouraged in healthcare settings.

Choice A rationale:

Avoiding quoting client comments when documenting is essential to maintain privacy and confidentiality. Quoting verbatim client statements may breach confidentiality and compromise the client's trust.

Choice B rationale:

Documenting giving a dose of pain medication just prior to administration is incorrect. Documentation should reflect the time, date, and relevant details of medication administration, including the client's response and any adverse effects.

Choice C rationale:

Documenting information telephoned in by a nurse who left the unit for the day is appropriate, as long as the information is pertinent to the client's care and documented accurately. Timely communication among healthcare providers is crucial for patient safety.

Choice D rationale:

Limiting documentation to subjective information is not advisable. Documentation should include both objective and subjective data to provide a comprehensive picture of the client's condition and care. Objective data includes vital signs, observations, and measurable findings.