A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

"It is acceptable to use alcohol-based hand products after most client contact.”

"I should wash my hands before I provide client care.”

"I will not wear artificial nails when providing client care.”

"As long as I change gloves between clients, it is not necessary to wash my hands.”

Answer and Explanation

The Correct Answer is D

Choice D rationale:

This statement by an assistive personnel (AP) indicates a need for further teaching. Hand hygiene is crucial to prevent the transmission of microorganisms, and it involves both handwashing and the appropriate use of gloves. Changing gloves between clients is important to prevent cross-contamination, but it doesn't replace the need for handwashing. Hands can become contaminated even with the use of gloves, and proper hand hygiene should be practiced before and after glove use.

Choice A rationale:

The statement about using alcohol-based hand products after most client contact is accurate. Alcohol-based hand sanitizers are effective in reducing the number of microorganisms on the hands when soap and water are not readily available. They are especially useful in healthcare settings.

Choice B rationale:

Washing hands before providing client care is a fundamental principle of infection control. It helps remove dirt, debris, and transient microorganisms from the hands, reducing the risk of infection transmission.

Choice C rationale:

The statement about not wearing artificial nails when providing client care is correct. Artificial nails can harbor microorganisms and are challenging to clean thoroughly. They pose an infection risk and are generally not recommended for healthcare workers who provide direct patient care.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale:

Placing the client in a modified Trendelenburg position is not the first intervention for a client with a deep laceration and heavy bleeding. This position involves tilting the patient with the head lower than the feet and is typically used to improve venous return in certain situations, such as hypovolemic shock. However, for a bleeding wound, the priority is to control the bleeding itself.

Choice B rationale:

Applying a tourniquet just above the wound is a drastic measure and is generally not the first intervention for controlling bleeding. Tourniquets are used when direct pressure and other methods are unsuccessful, as they can lead to complications such as tissue damage and ischemia if not used correctly.

Choice C rationale:

Starting two large-bore IV catheters is important for fluid resuscitation in cases of significant bleeding. However, it is not the first intervention. Directly controlling the bleeding takes precedence to prevent further blood loss.

Choice D rationale:

Applying pressure directly to the wound is the correct answer. This is the initial and immediate action to take when dealing with a heavily bleeding wound. Applying pressure helps to stem the bleeding by promoting clot formation and reducing blood loss. It is a vital step in managing the client's condition and preventing further deterioration.

A. Petechiae on the chest. B. Increased anteroposterior diameter of the chest. C. Oxygen saturation level 96%. D. Respiratory alkalosis.

Correct Answer is B

Explanation

The correct answer is choice B. Increased anteroposterior diameter of the chest.

Choice A rationale:

Petechiae on the chest (Choice A) are tiny red or purple spots that appear on the skin due to small blood vessel breakage. They are not typically associated with COPD and emphysema. Petechiae are more often related to conditions like thrombocytopenia or certain infections, where blood clotting is impaired.

Choice B rationale:

Increased anteroposterior diameter of the chest, often referred to as "barrel chest," is a characteristic finding in clients with COPD and emphysema. This occurs due to the hyperinflation of the lungs and the loss of elasticity in the lung tissues, which causes the chest to become rounded and the ribs to be positioned more horizontally.

Choice C rationale:

An oxygen saturation level of 96% (Choice C) is within the normal range for oxygen saturation. However, while it's important for clients with COPD to maintain adequate oxygen levels, this value doesn't specifically correlate with the client's symptoms of a wet cough and occasional shortness of breath.

Choice D rationale:

Respiratory alkalosis (Choice D) involves an increase in blood pH due to decreased levels of carbon dioxide (hypocapnia) caused by hyperventilation. While respiratory alkalosis can occur in clients with COPD due to compensatory hyperventilation, it is not a direct assessment finding related to the client's symptoms of a wet cough and occasional shortness of breath.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Correct Answer is D

Explanation

A nurse on a Medical-Surgical unit is performing an assessment on a client who has COPD with emphysema. The client reports that he has a frequent wet cough and is occasionally short-of-breath. The nurse should anticipate which of the following assessment findings for this client?

Correct Answer is B

Explanation

A nurse is caring for an Islamic client who is recovering from a motor vehicle accident. The patient is observing Ramadan, the ninth lunar month. The nurse understands that a good diet is important for the client's wounds to heal. Which action should the nurse take regarding the client's diet?

A nurse is admitting a client who has measles and a persistent cough. Which of the following actions is a priority for the nurse to take?

The nurse in the trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

A nurse is admitting a client who has hepatitis

A nurse is caring for a patient on a Medical-Surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first?

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?