A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

"Use an alcohol rub when your hands are visibly soiled."

"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

"If you wear gloves, you do not have to wash your hands."

"If you don't have an infection, your hands won't infect others."

Answer and Explanation

The Correct Answer is B

A. Using an alcohol rub when hands are visibly soiled is incorrect; hands should be washed with soap and water in such cases.

B. Rubbing all surfaces of the hands with an alcohol rub for 20 to 30 seconds is an appropriate practice for effective hand hygiene when hands are not visibly soiled, ensuring thorough coverage of all hand surfaces.

C. Gloves are not a substitute for hand hygiene; hands should be washed before putting on gloves and after removing them to prevent contamination.

D. Even if an individual does not have an infection, they can still carry pathogens on their hands that may infect others, highlighting the necessity of proper hand hygiene.

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Correct Answer is A

Explanation

A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.

B. Documenting that the medication was administered should occur after the medication has been given, not before.

C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.

D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30° to 45°. D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.

B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.

C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.

D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.

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A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first?

Correct Answer is A

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A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

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