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 C

Explanation

A. “I will follow a full-liquid diet the day before the procedure.": This is incorrect. Typically, clients are instructed to follow a clear-liquid diet the day before a colonoscopy, not a full-liquid diet. Clear liquids (e.g., water, broth, clear juices) are required to ensure the colon is fully cleaned out for the procedure.

B. “This procedure will take place while I'm under general anesthesia.”: This is incorrect. A colonoscopy is usually performed with moderate sedation or conscious sedation, not general anesthesia. The client may be sedated but will not be completely unconscious.

C. “I have my friend drive me home after the procedure.”: This is correct. After a colonoscopy, the sedation used for the procedure can impair the client's ability to drive. It is recommended that the client arrange for a friend or family member to drive them home.

D. “I can expect rectal bleeding for a week after the procedure.”: This is incorrect. Mild rectal bleeding can occur immediately after the procedure, but it should not last for a week. If bleeding persists beyond a day or two, the client should contact their healthcare provider.

A. The AP points the probe posteriorly. B. The AP pulls the pinna up and back. C. The AP positions the client facing her. D. The AP inserts the probe with a straight, forward motion.

Correct Answer is B

Explanation

A. The AP points the probe posteriorly is incorrect. When using a tympanic thermometer for adults or children older than 3 years, the probe should be directed posteriorly and slightly upwards to align with the ear canal. The posterior direction is correct for adults, but this phrasing is not precise enough for the intended technique.

B. The AP pulls the pinna up and back is correct. When taking the temperature of a client older than 3 years using a tympanic thermometer, the pinna (ear) should be pulled up and back to straighten the ear canal and ensure accurate measurement. This action indicates the AP understands proper technique.

C. The AP positions the client facing her is incorrect. The client’s position does not directly affect the ability to take a tympanic temperature. The focus should be on positioning the ear and probe, not on facing the nurse.

D. The AP inserts the probe with a straight, forward motion is incorrect. The correct motion is straight into the ear canal, not forward, and it is more precise when the probe is inserted gently without forcing it.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Correct Answer is B

Explanation

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