The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Washing for a total of 20 seconds.

Lathering using a circular movement.

Turning the water off using bare hands.

Holding hands below elbows when rinsing.

Answer and Explanation

The Correct Answer is C

Choice A reason: Washing for a total of 20 seconds is correct and meets hand hygiene guidelines.

Choice B reason: Lathering using a circular movement is an appropriate technique for thorough handwashing.

Choice C reason: Turning the water off using bare hands can lead to recontamination of the hands. The UAP should use a paper towel to turn off the faucet.

Choice D reason: Holding hands below elbows when rinsing is correct to allow water to run off the hands and prevent contamination.

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Correct Answer is B

Explanation

Choice A reason: Explaining the need for skin exposure to sunlight without sunscreen is not advisable because it can increase the risk of further skin damage or skin cancer, especially in a client with a history of severe burns. Sunscreen should be used to protect the skin from harmful UV rays.

Choice B reason: Teaching the need for dietary and supplemental vitamin D is important because clients with extensive burns often have impaired vitamin D synthesis due to reduced exposure to sunlight and possible nutritional deficiencies. Vitamin D is essential for bone health and muscle function.

Choice C reason: Instructing the client in the use of muscle strengthening exercises is beneficial for overall health, but it does not directly address the specific issue of bone pain and muscle weakness related to potential vitamin D deficiency.

Choice D reason: Encouraging progressive active range of motion is important for maintaining joint flexibility and function, but it does not directly address the underlying cause of bone pain and muscle weakness in this scenario.

A. Evaluate a client's mobility progress toward the plan of care. B. Titrate oxygen to the prescribed parameters. C. Procure platelet products from the blood bank. D. Determine the diameter and depth of a client's dermal ulcer.

Correct Answer is C

Explanation

Choice A reason: Evaluating a client's mobility progress involves assessment and clinical judgment, which are beyond the scope of practice for a UAP.

Choice B reason: Titrating oxygen requires clinical judgment and understanding of the client's condition, which should be performed by licensed nursing staff.

Choice C reason: Procuring platelet products from the blood bank is within the scope of practice for a UAP as it involves following protocols and retrieving items, not direct patient care.

Choice D reason: Determining the diameter and depth of a client's dermal ulcer involves assessment and clinical judgment, which should be performed by licensed nursing staff.

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The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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