A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

Dry hands thoroughly from fingers to wrist.

Hold the hands slightly higher than the elbows when using running water.

Wash hands under running water for at least 10 seconds.

Clean hands with alcohol-based hand gel for 16 seconds.

Answer and Explanation

The Correct Answer is A

A. Drying hands thoroughly from fingers to wrist is correct. Proper drying technique is important because residual moisture can harbor bacteria, and drying from fingers to wrist prevents recontamination of clean areas by water dripping from contaminated areas.

B. Holding hands slightly higher than the elbows when using running water is incorrect. The proper technique is to hold hands lower than the elbows to allow water to flow downward, preventing recontamination of clean areas by dirty water.

C. Washing hands under running water for at least 10 seconds is incorrect. The recommended duration for effective handwashing is at least 20 seconds with soap and water to ensure the removal of pathogens.

D. Cleaning hands with alcohol-based hand gel for 16 seconds is incorrect. The recommended time for using alcohol-based hand rubs is at least 20 seconds, ensuring thorough coverage of all surfaces for effective pathogen removal.

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Correct Answer is A

Explanation

A. Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.

B. Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination.

C. Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision.

D. Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.

A. Docusate B. Ibuprofen C. Aspirin D. Omeprazole

Correct Answer is A

Explanation

A. Docusate is correct. Docusate is a stool softener, and it does not have a significant effect on blood clotting. Therefore, it is considered safe for use with warfarin, which requires careful monitoring to avoid interactions that may increase bleeding risks.

B. Ibuprofen is incorrect. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID. that can increase the risk of bleeding when used with warfarin by inhibiting platelet aggregation and affecting clotting factors.

C. Aspirin is incorrect. Aspirin also inhibits platelet function, increasing the risk of bleeding when combined with warfarin. This combination should be avoided unless specifically prescribed.

D. Omeprazole is incorrect. Although omeprazole is often used to treat gastrointestinal issues, it may interact with warfarin and affect its metabolism. This interaction can increase the risk of bleeding, and caution is recommended when using these medications together.

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A nurse at a long-term care facility is part of a risk management team that is creating a plan to lower infection rates in the facility. Which of the following instructions regarding hand hygiene should the nurse include?

Nursing Test Bank

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