A client on the psychiatric unit is making sexual advances towards a nurse. Which action should this nurse implement first?

A. While supervision and evaluation are important for ongoing competency, immediate correction of the observed hand hygiene practice is more appropriate than waiting to observe in the next client’s room.

B. Gloves are not required for routine vital signs unless there is anticipated contact with bodily fluids or broken skin. Advising universal glove use is unnecessary and does not address proper hand hygiene.

C. Alcohol-based hand rubs are an accepted and effective method for hand hygiene in the absence of visible soiling. Returning to perform traditional handwashing is unnecessary unless hands are visibly dirty or contaminated with certain pathogens (e.g., Clostridium difficile).

D. Alcohol-based hand rubs must be applied correctly by covering all surfaces of the hands and rubbing until completely dry to achieve effective antisepsis. The UAP demonstrated correct use of hand rub, but the nurse should reinforce that rubbing until the hands are dry is essential for proper technique.

A. Intestinal obstruction is the most likely complication in a child post-Wilms tumor removal who presents with abdominal pain, distension, absent bowel sounds, and vomiting. Postoperative adhesions, bowel manipulation during surgery, or edema can impair intestinal motility, leading to obstruction. Early recognition and intervention are critical to prevent bowel ischemia or perforation.

B. Pyloric stenosis typically occurs in infants and presents with projectile vomiting, visible peristalsis, and a palpable “olive” in the abdomen. It is not a common postoperative complication in older children after abdominal tumor surgery.

C. Infectious gastritis usually presents with nausea, vomiting, and mild abdominal discomfort, but it does not typically cause absent bowel sounds or significant distension, making it less likely in this scenario.

D. Abdominal peritonitis is an inflammation of the peritoneum, often caused by perforation or infection. While it can cause severe abdominal pain and distension, it is usually associated with fever, rigidity, and severe tenderness. The gradual presentation of absent bowel sounds and vomiting aligns more closely with intestinal obstruction rather than acute peritonitis.