A nurse is assisting with staff education about hand hygiene.
Which of the following instructions should the nurse include in the teaching?
Wear sterile gloves when in contact with body fluids.
Use alcohol-based cleanser when hands are visibly soiled.
Artificial nails can be worn when performing direct client care.
Wash hands with soap and water for 20 seconds.
The Correct Answer is D
Explanation
D, Wash hands with soap and water for 20 seconds
Hand hygiene is a critical practice in preventing the transmission of infections in healthcare settings. Here's why the other options are incorrect:
Wearing sterile gloves when in contact with body fluids in (option A) is incorrect because it is important for preventing the transmission of pathogens, but it is not directly related to hand hygiene. Hand hygiene refers to the cleaning of hands to remove pathogens, and sterile gloves provide a barrier to protect the healthcare worker and the patient.
B. Using an alcohol-based cleanser when hands are visibly soiled in (option B) is not recommended. Alcohol-based cleansers are effective in killing many types of germs, but they are not as effective in removing visible dirt, blood, or body fluids. In such cases, it is important to wash hands with soap and water to thoroughly clean them.
Artificial nails should not be worn when performing direct client care in (option C). They can harbor and transmit pathogens and make it more difficult to effectively clean hands. The Centres for Disease Control and Prevention (CDC) recommends that healthcare workers maintain short, clean, and natural nails without the use of artificial nails or nail extensions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
During an external chemical disaster, it is crucial to minimize the exposure of clients to the hazardous substance. Moving clients to a room above ground level with few windows can help reduce the risk of exposure to the chemical and its fumes. This is because many hazardous chemicals tend to be denser than air and may settle closer to the ground. Choosing a room above ground level and with fewer windows can provide a safer environment.
Turning on fans in the facility to circulate air can actually worsen the situation by spreading the chemical and its fumes throughout the facility, potentially exposing more individuals.
Covering the electrical outlets with wet towels is not directly related to preparing for an external chemical disaster. It may be more relevant during a fire emergency to prevent the spread of flames, but not for chemical exposure.
Opening the fireplace dampers in the day room can allow the entry of outside air and potentially introduce more of the hazardous substance into the facility.
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.

"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.

"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.

"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.

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