Standard precautions are established by the Center for Disease Control (CDC) How would a nurse explain when standard precautions are to be used with a client?

Standard precautions are to be used for any client, regardless of whether an infection has been identified.

Standard precautions are used when the client has an infection that is transmitted on air currents.

Standard precautions are to be used when the client has a pathogen that can spread via moist droplets.

Standard precautions are only used when there is an infection that is spread by indirect contact with an organism.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Checking a restrained patient every 45 minutes might be too frequent and could interfere with the patient's rest and comfort, especially if the restraint is necessary for their safety. It could also lead to increased agitation and resistance from the patient, making it more challenging for the healthcare providers to manage the situation effectively.

Choice B rationale:

Checking on a restrained patient every 30 minutes is also too frequent for the reasons mentioned above. Patients need some time to rest and recover, and constant monitoring might be perceived as intrusive and threatening, potentially escalating the situation.

Choice C rationale:

Checking on a restrained patient every hour might not be sufficient, especially if the patient is at high risk of harming themselves or others. Waiting for an hour between checks could lead to dangerous situations, as a lot can happen in that time frame.

Choice D rationale:

Checking on a restrained patient every 2 hours strikes a balance between ensuring the patient's safety and respecting their privacy and comfort. It allows healthcare providers to monitor the patient's condition and intervene promptly if necessary while also giving the patient some space to rest and recover.

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Correct Answer is A

Explanation

Choice A rationale:

Proper hand-washing technique involves washing hands for at least 20 seconds. This duration ensures thorough cleansing and removal of germs, dirt, and contaminants from the hands. Washing for a shorter time, such as 10 seconds (Choice B), may not effectively eliminate all harmful microorganisms, increasing the risk of infections and transmission of diseases.

Choice B rationale:

Washing hands for only 10 seconds is insufficient to achieve the necessary level of cleanliness. It is essential to follow recommended guidelines to prevent the spread of infections in healthcare settings and other environments where hygiene is crucial.

Choice C rationale:

Washing hands for 45 seconds (Choice C) is longer than the recommended duration and might not be practical, especially in busy healthcare settings. While thorough hand hygiene is essential, excessively long washing times could lead to reduced compliance among healthcare workers, potentially compromising patient safety.

Choice D rationale:

Proper hand-washing technique involves scrubbing hands for at least 20 seconds, making Choice D incorrect. Following the recommended guidelines is crucial to maintaining a safe and hygienic healthcare environment.

A. Ties the straps of the restraints in a double knot. B. Ties the restraints to the side rails. C. Places the padding of the restraints against the client's bony prominences. D. Inserts one finger between the client's wrist and the restraint.

Correct Answer is B

Explanation

Choice A rationale:

Using a fire extinguisher should not be the nurse's first action in this situation. The nurse's priority is to ensure the safety of the clients and staff in the vicinity. Attempting to use a fire extinguisher might not be effective and can potentially cause harm, especially if the fire spreads quickly.

Choice B rationale:

Activating the fire alarm is the nurse's priority in this situation. By activating the fire alarm, the nurse can alert everyone in the facility about the fire, ensuring that people are aware and can evacuate safely. This action initiates the facility's fire response protocol, leading to a quicker and organized response to the emergency.

Choice C rationale:

Moving clients to safety is important, but it is not the nurse's immediate priority in this situation. Activating the fire alarm should be done first to ensure that everyone in the facility is aware of the danger, and then the nurse can assist in moving clients to safety if necessary.

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Standard precautions are established by the Center for Disease Control (CDC) How would a nurse explain when standard precautions are to be used with a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client, the nurse knows the best method to reduce healthcare-associated infections (HAIs) is to do what?

Correct Answer is A

Explanation

A charge nurse is reinforcing teaching for a newly licensed nurse about how to apply wrist restraints for a client.Which of the following actions should the charge nurse identify as an indication that the nurse understands the instructions?

Correct Answer is B

Explanation

A nurse explains to a client that it is important to slowly change positions to diminish or eliminate the symptoms of what?

A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority?

When the nurse is preparing a sterile field using the drape provided in a sterile pack, the nurse would only touch which part of the sterile drape?

A nurse is preparing to conduct a fall risk screening on a client.Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)

A nurse explains to a client with hypertension that diastolic pressure is a measurement of what?

Proper hand-washing technique requires that a nurse wash for a minimum of what length of time?

The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?