A nurse is assisting with teaching a newly licensed about hand hygiene. Which of the following instructions should the nurse include?

Use hot water when washing hands with soap and water.

Use alcohol-based hand sanitizers on hands for at least 10 seconds.

Wash hands with soap and water if they are visibly soiled.

Wash hands with an alcohol-based hand sanitizer when caring for a client who has Clostridium difficile.

Answer and Explanation

The Correct Answer is C

A.   While water temperature can be a matter of personal preference, it is not necessary to use hot water. In fact, the temperature of the water (whether warm or cold) does not significantly impact the effectiveness of handwashing. The most important factor is to use soap and rub the hands thoroughly for at least 20 seconds.
B.   This statement is partially correct but requires clarification. Alcohol-based hand sanitizers should be rubbed on all surfaces of the hands until they are dry, which typically takes about 20 seconds. Ten seconds is insufficient for effective sanitization, so this instruction should be revised.
C.   This statement is correct and should definitely be included. When hands are visibly soiled, washing them with soap and water is the most effective way to remove dirt, bacteria, and viruses. Alcohol-based hand sanitizers are not effective when hands are dirty or greasy.
D.   Clostridium difficile (C. diff) infections require soap and water for handwashing, as alcohol-based hand sanitizers are ineffective against the spores of C. diff. Therefore, this instruction should not be included.

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Correct Answer is D

Explanation

A. This involves providing information and teaching individuals about health-related topics to improve their knowledge, skills, and behaviors. However, this is a narrower term.
B. This involves preventing the occurrence of a disease or injury before it happens. While the nurse's advice is aimed at improving the client's health and reducing the risk of heart disease, it doesn't directly prevent the occurrence of the disease.
C. This approach considers the whole person, including physical, mental, emotional, and spiritual aspects. While a heart-healthy diet can contribute to overall well-being, it doesn't encompass all aspects of holistic health.
D. This involves creating conditions that enable people to lead healthy lives. While the nurse's advice can contribute to health promotion, it's not the primary focus of the interaction.

A. Planning B. Implementation C. Evaluation D. Data collection

Correct Answer is A

Explanation

A. The planning step involves setting goals and determining appropriate interventions to achieve desired outcomes for the client. During this phase, the nurse collaborates with the healthcare team, including
the RN, to establish measurable and realistic goals tailored to the client’s needs.
B. This step refers to the execution of the planned interventions. It involves carrying out the nursing actions and strategies that were developed during the planning phase. While important, implementation is not the stage where goals are formulated.
C. Evaluation is the step where the nurse assesses the effectiveness of the interventions and whether the goals have been met. This phase involves reviewing the client’s progress and determining if adjustments are needed for the care plan. Formulating goals occurs prior to this step.
D. This step is part of the assessment phase, where the nurse gathers information about the client’s health status, history, and needs. While data collection is essential for informing the planning process, it does not involve the formulation of goals.

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A nurse is assisting with teaching a newly licensed about hand hygiene. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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