A nurse on a pediatric unit is caring for a toddler who has poor dietary intake.

Which of the following actions should the nurse take first?

Explanation

D, Wash hands with soap and water for 20 seconds

Hand hygiene is a critical practice in preventing the transmission of infections in healthcare settings. Here's why the other options are incorrect:

Wearing sterile gloves when in contact with body fluids in (option A) is incorrect because it is important for preventing the transmission of pathogens, but it is not directly related to hand hygiene. Hand hygiene refers to the cleaning of hands to remove pathogens, and sterile gloves provide a barrier to protect the healthcare worker and the patient.

B. Using an alcohol-based cleanser when hands are visibly soiled in (option B) is not recommended. Alcohol-based cleansers are effective in killing many types of germs, but they are not as effective in removing visible dirt, blood, or body fluids. In such cases, it is important to wash hands with soap and water to thoroughly clean them.

Artificial nails should not be worn when performing direct client care in (option C). They can harbor and transmit pathogens and make it more difficult to effectively clean hands. The Centres for Disease Control and Prevention (CDC) recommends that healthcare workers maintain short, clean, and natural nails without the use of artificial nails or nail extensions.

Understanding the client's current voiding pattern is essential in developing an effective bladder training program. By determining the client's pattern for voiding, the nurse can identify any irregularities, frequency, and specific times when the client is more likely to void. This information will serve as a baseline for developing an individualized bladder training program. Offering toileting opportunities every 1 to 2 hours is an appropriate intervention to ensure regular and scheduled voiding. However, before implementing this intervention, it is necessary to determine the client's current voiding pattern to identify any existing irregularities or potential areas of improvement.

Assisting the client with relaxation techniques can help promote effective voiding and reduce anxiety or stress related to the act of voiding. However, this intervention can be more effective once the nurse has assessed the client's voiding pattern and identified specific areas where relaxation techniques can be beneficial.

Discouraging intake of carbonated beverages is a valid intervention as carbonated beverages can irritate the bladder and contribute to increased frequency and urgency of urination. However, this intervention can be implemented as part of a comprehensive bladder training program after the nurse has assessed the client's current voiding pattern and developed an individualized plan.