A nurse is assisting with staff education about hand hygiene. Which of the following instructions should the nurse include in the teaching?

Wash hands with soap and water for 20 seconds.

Artificial nails can be worn when performing direct client care.

Wear sterile gloves when in contact with body fluids.

Use alcohol-based cleanser when hands are visibly soiled.

Answer and Explanation

The Correct Answer is A

Wash hands with soap and water for 20 seconds: Washing hands with soap and water is the preferred method for hand hygiene in most situations, especially when hands are visibly soiled or contaminated with body fluids. The CDC recommends washing hands for at least 20 seconds, ensuring that all surfaces of the hands, including the back of the hands, between the fingers, and under the nails, are thoroughly cleaned.

Artificial nails should not be worn when performing direct client care: Artificial nails, including nail extensions and overlays, should be avoided when providing direct client care. The wearing of

artificial nails can increase the risk of bacterial colonization and make proper hand hygiene more challenging. Short, natural nails without nail polish are recommended for healthcare workers to ensure effective hand hygiene and reduce the risk of infection transmission.

Wear sterile gloves when in contact with body fluids: Sterile gloves are indicated when there is a need for an aseptic technique or when in contact with sterile body sites or invasive procedures.

However, for routine patient care and non-sterile procedures, non-sterile disposable gloves are typically sufficient. The use of gloves does not replace the need for proper hand hygiene before and after glove use.

Use alcohol-based cleanser when hands are visibly soiled: Alcohol-based hand sanitizers are effective in killing many types of germs when used correctly. However, they are not as effective when hands are visibly soiled or contaminated with body fluids. In such cases, washing hands with soap and water is recommended to ensure proper cleansing and removal of visible dirt or contaminants.

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Correct Answer is C

Explanation

A.Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.

B.This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.

C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.

D.While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.

A. Hgb 13.2 g/dL B. BUN 15 mg/dL C. Urine protein 3+ D. Fasting blood glucose 72 mg/dL

Correct Answer is C

Explanation

Proteinuria can indicate kidney dysfunction or potential complications in pregnancy, such as preeclampsia. The provider needs to be aware of this finding and may want to assess the client further and consider appropriate interventions.

The other laboratory values are within normal ranges and do not require immediate reporting. Hgb (hemoglobin) of 13.2 g/dL is within the normal range for pregnancy. BUN (blood urea nitrogen) of 15 mg/dL is within the normal range, indicating normal kidney function. Fasting blood glucose of 72 mg/dL is within the normal range and indicates normal blood sugar levels.

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