The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Washing for a total of 20 seconds.

Lathering using a circular movement.

Turning the water off using bare hands.

Holding hands below elbows when rinsing.

Answer and Explanation

The Correct Answer is C

Choice A reason: Washing for a total of 20 seconds is correct and meets hand hygiene guidelines.

Choice B reason: Lathering using a circular movement is an appropriate technique for thorough handwashing.

Choice C reason: Turning the water off using bare hands can lead to recontamination of the hands. The UAP should use a paper towel to turn off the faucet.

Choice D reason: Holding hands below elbows when rinsing is correct to allow water to run off the hands and prevent contamination.

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Correct Answer is C

Explanation

Choice A reason: Divalproex is not used for treating acute dystonic reactions.

Choice B reason: Lorazepam can be used for certain types of acute reactions but is not the first line of treatment for dystonic reactions with laryngeal spasm.

Choice C reason: IV administration of benztropine is appropriate for treating acute dystonic reactions, including laryngeal spasm, as it helps to relieve the muscle contractions.

Choice D reason: IV administration of isotonic crystalloid fluid is not a treatment for dystonic reactions but may be used to maintain hydration and electrolyte balance.

A. Mix the next dose with food. B. Administer a half dose now. C. Withhold this dose. D. Give another dose.

Correct Answer is C

Explanation

Choice A reason: Mixing the next dose with food is not recommended because digoxin is better absorbed on an empty stomach and food may interfere with its absorption. Additionally, this option does not address the immediate issue of the infant vomiting after the dose.

Choice B reason: Administering a half dose is not appropriate because it may lead to incorrect dosing and potential under-treatment or toxicity. The exact dose must be given according to medical guidelines.

Choice C reason: Withholding the dose is the best course of action. If an infant vomits after receiving a dose of medication, particularly a critical one like digoxin, it is essential to wait until the next scheduled dose to avoid potential overdose or toxic effects.

Choice D reason: Giving another dose is not recommended because it could lead to toxicity, especially considering the infant might have partially absorbed the initial dose before vomiting.

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The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is C

Explanation

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

Correct Answer is C

Explanation

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