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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Yankauer catheter: A Yankauer catheter is a rigid suction device designed for clearing oral secretions, primarily in the mouth and pharynx. It is not suitable for tracheostomy suctioning because it cannot safely reach into the trachea and may cause trauma if used intratracheally. Tracheostomy suctioning requires a flexible, sterile suction catheter.
B. Sterile water: Sterile water or sterile saline is used to flush the suction catheter before and after tracheostomy suctioning. It helps maintain catheter patency and clears secretions, reducing the risk of obstruction during the procedure. Using sterile solutions also prevents introducing pathogens into the airway, which is critical for infection prevention.
C. Nasal cannula: A nasal cannula delivers supplemental oxygen but is not used for the suctioning procedure itself. While oxygen may be administered before or after suctioning to prevent hypoxia, it is not considered essential equipment for performing the suctioning procedure.
D. Pulse oximeter: A pulse oximeter is used to monitor oxygen saturation and assess the client’s response to suctioning. Although important for patient safety, it is not a piece of equipment required to perform the suctioning procedure; rather, it serves as a monitoring device to guide intervention.
Correct Answer is B
Explanation
Rationale:
A. "I will weigh myself daily." Weighing oneself daily is a recommended practice for clients with heart failure to monitor fluid retention. It does not suggest a need for cardiac rehabilitation as it helps with self-management.
B. "I'm too tired to brush my teeth." This statement suggests severe fatigue and reduced physical functioning, indicating the need for cardiac rehabilitation. It can help improve endurance, strength, and overall quality of life.
C. "I hate how I feel all the time." This statement indicates dissatisfaction with the condition, but it does not suggest a specific need for cardiac rehabilitation. It may signal emotional distress or depression, but not necessarily a physical activity issue.
D. "I need to start eating a low-sodium diet." Eating a low-sodium diet is part of heart failure management, it does not indicate the need for cardiac rehabilitation. Diet changes are essential but don't directly relate to physical rehabilitation.
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