The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Remind the UAP to continue rubbing the hands together until they are dry.

Instruct the UAP to return to the client's room to perform handwashing.

Supervise the UAP in the next client's room to evaluate hand hygiene.

Advise the UAP to wear gloves when obtaining vital signs for all clients.

Answer and Explanation

The Correct Answer is A

A.   Reminding the UAP to continue rubbing the hands together until they are dry ensures proper use of the hand rub, which is effective when fully dry.
B.   Handwashing with soap and water is necessary after certain activities (e.g., after using the restroom, or when hands are visibly soiled), but using an alcohol-based hand rub is appropriate for routine hand hygiene.
C.   Supervising in the next client's room is less direct and immediate than ensuring proper technique now.
D.   Wearing gloves for all clients is not necessary and does not replace proper hand hygiene.

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Correct Answer is D

Explanation

A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.

A. Begin with questions that are less sensitive in nature. B. Share personal values to put the client at ease. C. Get the most difficult questions over with first. D. Ask questions in a vague, non-specific format.

Correct Answer is A

Explanation

A.Beginning with less sensitive questions helps establish trust and rapport with the client, making it easier to discuss more difficult topics later. This approach can make the client feel more comfortable and less threatened, thereby improving the quality of the information gathered.

B.Sharing personal values can introduce bias and potentially influence the client's responses, making the interview less objective.

C.Starting with the most difficult questions can make the client feel anxious and defensive, reducing the likelihood of obtaining honest and thorough responses.

D.Asking vague, non-specific questions can lead to ambiguous answers and fail to provide the detailed information needed for a proper assessment.

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The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

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