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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is a. Plan to remove the restraints as soon as the client is calm.

Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.

Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.

Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.

Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.

A. Laissez-faire leadership style. B. Self-blame for financial problems. C. High self-esteem. D. Rigid expectations of behavior.

Correct Answer is D

Explanation

Choice A rationale:

A laissez-faire leadership style is characterized by a lack of involvement or control, and it is not typically associated with perpetrators of child abuse.

Choice B rationale:

Self-blame for financial problems may lead to stress but is not a characteristic finding of perpetrators of child abuse.

Choice C rationale:

High self-esteem is not typically associated with perpetrators of child abuse. In fact, abusers often have low self-esteem and exert power and control over others to compensate for it.

Choice D rationale:

Perpetrators of child abuse often have rigid expectations of behavior from their children and may employ authoritarian parenting styles. This characteristic can contribute to abusive behaviors.

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

Nursing Test Bank

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