Proper hand-washing technique requires that a nurse wash for a minimum of what length of time?

30 seconds.

10 seconds.

45 seconds.

20 seconds.

Answer and Explanation

The Correct Answer is D

Choice B rationale:

Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.

Choice A rationale:

Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.

Choice C rationale:

Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.

Choice D rationale:

Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.

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Correct Answer is A

Explanation

Choice A rationale:

The client's respirations are faster and deeper than normal due to expelling too much carbon dioxide. This condition is known as hyperventilation. Hyperventilation can occur due to various reasons such as anxiety, pain, fever, or metabolic acidosis. When the body expels excessive carbon dioxide, it leads to respiratory alkalosis, resulting in faster and deeper breathing to compensate for the decrease in carbon dioxide levels in the blood.

Choice B rationale:

This option is incorrect. Hypoxemia, or low blood oxygen levels, typically leads to rapid, shallow breathing (tachypnea) rather than deep and fast respirations.

Choice C rationale:

This option is incorrect. Inflammation of the phrenic nerve does not directly affect the depth and rate of respirations. Phrenic nerve inflammation is more likely to cause pain during breathing or hiccups.

Choice D rationale:

This option is incorrect. Using intercostal muscles to breathe is a normal physiological process, especially during deep or labored breathing. However, it does not explain the specific situation described in the question, where the respirations are faster and deeper than normal.

A. Retie the restraint straps with a slipknot. B. Check that three fingers will fit beneath the restraints. C. Retie the restraint straps to the side rails. D. Remove the padding under the wrist restraints.

Correct Answer is A

Explanation

The correct answer is choice a. Retie the restraint straps with a slipknot.

Choice A rationale:

The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.

Choice B rationale:

It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.

Choice C rationale:

Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.

Choice D rationale:

The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.

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Proper hand-washing technique requires that a nurse wash for a minimum of what length of time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing peripheral pulses on a client and is aware that which action is a safety issue when assessing the client's peripheral pulses?

Correct Answer is A

Explanation

A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Which vowel is most commonly used when combining word parts?

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When caring for a client, the nurse knows the best method to reduce healthcare-associated infections (HAIs) is to do what?

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A nurse notes a client's pulse is a 2+ and understands this means what about the pulse?

Which medical term means kidney?

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