The nurse observes an unlicensed assistive personnel (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.

Turning the water off using bare hands.

Holding hands below elbows when rinsing.

Lathering using a circular movement.

Answer and Explanation

The Correct Answer is B

Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.

Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.

Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.

Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.

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Correct Answer is D

Explanation

Choice A reason: Assessing for discomfort is important, but it is not a safety intervention that should be implemented during the creation of a sterile field.

Choice B reason: Instructing the client to keep hands under the sterile field is not practical or safe, especially since the client is mildly confused and may not be able to follow such instructions.

Choice C reason: Pouring cleansing solution onto the sterile cloth field is part of the debridement process but does not directly relate to client safety.

Choice D reason: Verifying informed consent is crucial for client safety to ensure that the client understands the procedure and agrees to it, especially when the client is confused.

A. Avoid prolonged standing or sitting. B. Cross legs at the knee but not at the ankle. C. Continue wearing compression stockings. D. Use a recliner for long periods of sitting. E. Maintain the bed flat while sleeping.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is: a, c, d.

Choice A: Avoid prolonged standing or sitting

Reason: Prolonged standing or sitting can exacerbate symptoms of chronic venous insufficiency (CVI) by increasing venous pressure and promoting blood pooling in the legs. Movement helps to enhance venous return and reduce swelling.

Choice B: Cross legs at the knee but not at the ankle

Reason: Crossing legs at the knee can impede blood flow and increase venous pressure, which is counterproductive for managing CVI. It is generally advised to avoid crossing legs at the knee to promote better circulation.

Choice C: Continue wearing compression stockings

Reason: Compression stockings are a cornerstone in the management of CVI. They help to improve venous return, reduce swelling, and prevent blood from pooling in the legs. Compression stockings should be worn as prescribed, typically during the day and removed at night.

Choice D: Use a recliner for long periods of sitting

Reason: Using a recliner can help elevate the legs above heart level, which reduces venous pressure and promotes venous return. This position can help alleviate symptoms of CVI.

Choice E: Maintain the bed flat while sleeping

Reason: Maintaining the bed flat while sleeping is not recommended for CVI management. Elevating the legs while sleeping can help reduce venous pressure and prevent blood from pooling in the legs.

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

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Naxlex Comprehensive Predictor Exams

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

Correct Answer is D

Explanation

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. What instruction(s) should the nurse include in the client's discharge teaching plan? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Choice A: Avoid prolonged standing or sitting

Choice B: Cross legs at the knee but not at the ankle

Choice C: Continue wearing compression stockings

Choice D: Use a recliner for long periods of sitting

Choice E: Maintain the bed flat while sleeping

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