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.
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.
The Correct Answer is A
Choice A rationale:
The nurse should include the instruction to wash hands with soap and water for 20 seconds in the teaching. This is a fundamental aspect of hand hygiene in healthcare settings. The rationale for this choice is that proper handwashing with soap and water for at least 20 seconds is the most effective way to remove dirt, debris, and transient microorganisms from the hands. It helps prevent the spread of infections, including those caused by viruses and bacteria.
Choice B rationale:
Wearing sterile gloves when in contact with body fluids is not directly related to hand hygiene education. While wearing gloves is an essential infection control practice, it is not a substitute for proper handwashing. Hand hygiene should be performed before donning gloves and after removing them.
Choice C rationale:
Using alcohol-based cleanser when hands are visibly soiled is not the best instruction for hand hygiene. Alcohol-based hand sanitizers are effective when hands are not visibly soiled. In cases of visible soiling, handwashing with soap and water is recommended to physically remove dirt and contaminants.
Choice D rationale:
Artificial nails should not be worn when performing direct client care as they can harbor microorganisms and make it challenging to clean the hands adequately. The use of artificial nails can increase the risk of transmitting infections to patients, which is why they should be discouraged in healthcare settings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
Choice B rationale:
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
Choice C rationale:
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
Choice D rationale:
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
Correct Answer is D
Explanation
Choice A rationale:
The client does not need an oxygen mask for a low flow rate of 1 to 2 L/min. Oxygen masks are typically used for higher flow rates and may not be comfortable or necessary for a client requiring such a low oxygen flow.
Choice B rationale:
A reservoir bag is not required for a client receiving low flow oxygen at 1 to 2 L/min. Reservoir bags are commonly used with oxygen masks at higher flow rates to ensure a consistent supply of oxygen during inhalation.
Choice C rationale:
Petroleum jelly is not a necessary supply for a client prescribed home oxygen at 1 to 2 L/min. Its use may not be recommended due to the risk of flammability in the presence of oxygen.
Choice D rationale:
The correct choice is D. The client should have a nasal cannula as a supply upon discharge. A nasal cannula is the appropriate delivery device for low flow oxygen therapy at 1 to 2 L/min. It is comfortable and allows for adequate oxygen supplementation for the client.
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