A nurse is teaching a group of assistive personnel about performing hand hygiene when caring for a client who has an immunodeficiency disorder. Which of the following information should the nurse include in the teaching?

Decontaminate hands with an alcohol-based hand rub after taking the client's pulse.

Dry hands by starting from the wrist and moving toward the fingers.

Wash hands with an alcohol-based hand rub if you have artificial nails.

Lather hands with soap and apply friction under running water for 5 seconds.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Decontaminate hands with an alcohol-based hand rub after taking the client's pulse:
Alcohol-based hand rubs are effective for decontaminating hands after routine tasks like taking a pulse, provided hands are not visibly soiled. They are effective in removing most pathogens, making them ideal.

B. Dry hands by starting from the wrist and moving toward the fingers: Hands should be dried by patting them gently with a clean paper towel, starting from the fingers and moving toward the wrist. This technique reduces the risk of transferring pathogens to clean areas.

C. Wash hands with an alcohol-based hand rub if you have artificial nails: Alcohol-based hand rubs should not be used if artificial nails are present, as they may not effectively remove pathogens from under the nails. Handwashing with soap and water is preferred in these cases.

D. Lather hands with soap and apply friction under running water for 5 seconds: Handwashing should involve lathering with soap for at least 20 seconds, not 5, to ensure that friction is applied across all areas of the hands to remove pathogens effectively.

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Correct Answer is C

Explanation

Rationale:

A. Apply a blood pressure cuff: Applying a blood pressure cuff is not the first priorit. The nurse’s first priority should be assessing the client’s circulation and responsiveness. Blood pressure measurement can be done after confirming the client's pulse and overall condition.

B. Establish an IV access: While establishing an IV access may be necessary for medication administration or fluid resuscitation, the immediate concern is assessing the client’s airway, breathing, and circulation. IV access should be obtained after ensuring that these basic life-sustaining functions are stable.

C. Palpate for the client's carotid pulse: The first step in evaluating an unresponsive client who is breathing is to check for a pulse to assess circulation. The nurse should palpate the carotid pulse to determine whether the client has a pulse and is adequately perfusing.

D. Initiate cardiac monitoring for the client: Cardiac monitoring is important, but it is not the first action to take when a client is unresponsive. The nurse should first assess the client’s pulse and breathing to ensure they are receiving adequate circulation before monitoring.

A. Tilt the client's head with the affected ear facing up. B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal. C. Point the tip of the syringe toward the top of the ear canal. D. Use cool fluid for irrigation.

Correct Answer is C

Explanation

Rationale:

A. Tilt the client's head with the affected ear facing up: Tilting the head with the affected ear facing up is not recommended. The head should be tilted so the affected ear faces downward, allowing the irrigating fluid to drain out easily and reducing the risk of injury or discomfort.

B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal: The syringe tip should not be inserted deeply into the ear canal. Inserting the tip too far can cause trauma to the ear canal or eardrum. The tip should be placed at the opening of the ear canal to allow for safe irrigation.

C. Point the tip of the syringe toward the top of the ear canal: The syringe should be aimed toward the top or posterior wall of the ear canal, not directly at the eardrum. This allows the fluid to flow along the ear canal and helps prevent injury to the eardrum while effectively flushing the ear.

D. Use cool fluid for irrigation: Cool fluid can cause dizziness or discomfort for the client. It is better to use warm, body-temperature fluid during ear irrigation to ensure the client remains comfortable and to avoid any adverse effects.

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A nurse is teaching a group of assistive personnel about performing hand hygiene when caring for a client who has an immunodeficiency disorder. Which of the following information should the nurse include in the teaching?

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