A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

Rinse their forearms with running water before applying soap.

Hold their hands above elbow level while washing and rinsing.

Generate a lather by rubbing their hands together vigorously for 5 seconds.

Turn off the faucet with a clean paper towel after drying hands.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D.

Choice A rationale:

Rinsing forearms with running water before applying soap is not a recommended step in the handwashing procedure. The primary step is to wet the hands, apply soap, and create a lather.

Choice B rationale:

Holding hands above elbow level while washing and rinsing is not a standard practice for handwashing. The hands should be washed thoroughly, and the focus is on scrubbing the hands, not their positioning.

Choice C rationale:

Generating a lather by rubbing hands together vigorously for 5 seconds is insufficient for effective handwashing. Proper handwashing involves rubbing hands together for at least 20 seconds to ensure thorough cleaning.

Choice D rationale:

The correct answer. After washing and drying hands, turning off the faucet with a clean paper towel is recommended to avoid recontaminating the clean hands. Touching the faucet directly with clean hands could potentially transfer pathogens back onto the hands.

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Correct Answer is D

Explanation

The correct answer is choiced. "Describe your concerns about sleeping to me.".

Choice A rationale:

While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.

Choice B rationale:

Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.

Choice C rationale:

Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.

Choice D rationale:

Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears.This allows the nurse to understand the client’s perspective and provide appropriate emotional support.

A. "I know that I can change my advance directives if I need to in the future.” B. "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney.” C. "My family can overrule the decisions made by my health care surrogate.” D. "Advance directives from one state are valid in any other state.”

Correct Answer is A

Explanation

The correct answer is choice A: "I know that I can change my advance directives if I need to in the future."

Choice A rationale:

This statement indicates an understanding of advance directives. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in case they become unable to make decisions themselves. It's important for clients to know that they can update or change their advance directives if their wishes or circumstances change over time.

Choice B rationale:

The statement that the health care surrogate will make decisions as soon as the power of attorney is signed is not accurate. Generally, a health care surrogate's authority to make decisions comes into effect when the primary individual is no longer able to make decisions themselves. Signing a power of attorney alone does not grant immediate decision-making power to the surrogate.

Choice C rationale:

The family generally cannot overrule the decisions made by a designated health care surrogate. Once an individual designates a surrogate and provides clear instructions through advance directives, the surrogate's decisions are legally binding and typically override the family's input.

Choice D rationale:

Advance directives are not universally valid across states. Laws and regulations regarding advance directives can vary significantly from state to state. It's important for clients to understand that if they relocate, they may need to update their advance directives to comply with the laws of the new state.

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A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands?

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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