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 C
Explanation
Choice A reason: Apple juice is an appropriate choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without putting strain on the digestive system. Apple juice is easily digestible and does not contain any solid particles that could be problematic for a client recovering from abdominal surgery.
Choice B reason: Smoothies can be included in a full liquid diet as long as they are well-blended and do not contain any solid chunks. Smoothies can provide essential nutrients and calories, which are important for recovery. They can be made with fruits, vegetables, and protein supplements to ensure a balanced intake.
Choice C reason: Mashed potatoes and gravy are not suitable for a full liquid diet. Although mashed potatoes are soft, they are not liquid and can be difficult to digest for someone on a full liquid diet. The gravy may also contain small particles or thickeners that are not appropriate for this diet. A full liquid diet is intended to include only foods that are completely liquid or will turn to liquid at room temperature.
Choice D reason: Chicken broth is an excellent choice for a full liquid diet. It is a clear liquid that provides hydration and some nutrients without adding any solid particles to the diet. Chicken broth is gentle on the digestive system and can help maintain electrolyte balance.
Correct Answer is B
Explanation
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.
Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.
Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.
Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.
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