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 C
Explanation
Choice A rationale:
"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.
Choice B rationale:
"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.
Choice C rationale:
"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.
Choice D rationale:
"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.
Correct Answer is B
Explanation
Choice A rationale:
A boggy fundus 3 fingerbreadths above the umbilicus is not an expected finding after receiving oxytocin for excessive vaginal bleeding. This finding could indicate uterine atony, which is a concern, but it is not a typical immediate response to oxytocin.
Choice B rationale:
The client reporting uterine cramping is an expected finding after receiving oxytocin. Oxytocin is often administered to stimulate uterine contractions and reduce bleeding, so uterine cramping is a positive response to the medication.
Choice C rationale:
Saturation of perineal pad in 15 minutes is not an expected finding after receiving oxytocin. Excessive bleeding would be a concern, and the nurse should monitor for signs of hemorrhage.
Choice D rationale:
The client reporting burning with urination is not an expected finding related to oxytocin administration. This symptom could be indicative of a urinary tract infection or another issue unrelated to oxytocin. It should be assessed and addressed separately.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.