A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?
Rub soap on hands for 20 seconds.
Allow hands and arms to dry.
Hold the hands higher than the elbows.
Adjust the water temperature to feel hot.
The Correct Answer is A
Effective hand hygiene is crucial in preventing the spread of infections in healthcare settings. The Centers for Disease Control and Prevention (CDC) and other health organizations provide guidelines on proper hand hygiene techniques to ensure maximum effectiveness.
Choice A Reason:
“Rub soap on hands for 20 seconds.”
This is the correct action for effective hand hygiene. According to the CDC, scrubbing your hands for at least 20 seconds is essential to remove germs effectively. This duration ensures that all surfaces of the hands, including the backs, between the fingers, and under the nails, are thoroughly cleaned. The CDC recommends singing the “Happy Birthday” song twice as a timer to ensure you scrub for the full 20 seconds.
Choice B Reason:
“Allow hands and arms to dry.”
While drying hands is an important step in hand hygiene, it is not the primary action that makes hand hygiene effective. The focus should be on the thorough scrubbing and cleaning of the hands. After washing, hands should be dried using a clean towel or air dryer to prevent the transfer of germs from wet hands.
Choice C Reason:
“Hold the hands higher than the elbows.”
This technique is often used in surgical hand antisepsis to prevent water from running from the hands down to the elbows, potentially contaminating the hands again. However, for routine hand hygiene, this is not necessary. The primary focus should be on the thorough washing and scrubbing of the hands.
Choice D Reason:
“Adjust the water temperature to feel hot.”
The temperature of the water is less important than the act of scrubbing itself. The CDC states that hands can be washed with either warm or cold water. The key is to use soap and scrub all surfaces of the hands for at least 20 seconds. Hot water can actually be harsh on the skin and is not required for effective hand hygiene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Atelectasis is a common postoperative complication, especially in patients who have undergone abdominal or thoracic surgery. It occurs when the alveoli in the lungs collapse, leading to reduced or absent breath sounds in the affected areas. This condition can result from shallow breathing, pain, or immobility after surgery. The absence of breath sounds in the bases of the lungs is a key indicator of atelectasis. Preventive measures include encouraging deep breathing exercises, using incentive spirometry, and early mobilization of the patient.
Choice B Reason:
Pulmonary embolism (PE) is a serious condition where a blood clot travels to the lungs, causing a blockage in one of the pulmonary arteries. While PE can present with symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, it is less likely to cause absent breath sounds in the lung bases. Instead, PE may lead to decreased oxygen levels and respiratory distress. Diagnosis typically involves imaging studies such as a CT pulmonary angiography.
Choice C Reason:
Arterial thrombus refers to a blood clot that forms in an artery, which can lead to tissue ischemia and infarction. This condition is more commonly associated with cardiovascular events such as myocardial infarction or stroke. It does not typically present with absent breath sounds in the lungs. Instead, symptoms may include pain, pallor, and loss of function in the affected area. Diagnosis and treatment focus on restoring blood flow to the affected tissues.
Choice D Reason:
Pneumonia is an infection of the lungs that can cause symptoms such as cough, fever, and difficulty breathing. While pneumonia can lead to abnormal breath sounds, such as crackles or wheezes, it is less likely to cause completely absent breath sounds in the lung bases. Pneumonia is usually diagnosed through clinical examination, chest X-rays, and sputum cultures. Treatment involves antibiotics and supportive care to manage symptoms.
Correct Answer is B
Explanation
Choice A reason: Referring a client because the unit is too busy is not an appropriate reason for a healthcare referral. Referrals should be based on the client’s specific needs and the expertise required to address those needs. Overcrowding or busyness of a unit should be managed through internal resources and staffing adjustments rather than referrals.
Choice B reason: When the care needed for the client is out of the healthcare provider’s scope of practice, a referral is necessary. This ensures that the client receives the appropriate level of care from a specialist or another provider with the required expertise. Referrals help in providing comprehensive and specialized care that the initial provider may not be equipped to deliver.
Choice C reason: Referring a client because they do not have insurance is not appropriate. Healthcare providers should assist clients in finding resources and support for their care needs, regardless of their insurance status. Referrals should be based on clinical needs, not financial or insurance considerations.
Choice D reason: Referring a client because they are late is not a valid reason for a healthcare referral. Timeliness is important, but it should not determine the need for a referral. Providers should address the reasons for lateness and work with the client to ensure they receive the necessary care.
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