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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

A. Secure the oxygen tubing to the bed sheet near the client’s head. B. Attach a humidifier bottle to the base of the flow meter. C. Apply petroleum jelly to the nares as needed to soothe mucous membranes. D. Remove the nasal cannula while the client eats.

Correct Answer is B

Explanation

Choice A Reason:

Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.

Choice B Reason:

Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.

Choice C Reason:

Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.

Choice D Reason:

Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.

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A nurse is preparing to perform hand hygiene. Which action should the nurse take for hand hygiene to be effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Correct Answer is A

Explanation

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which action should the nurse take?

Correct Answer is B

Explanation

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