The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Remind the UAP to continue rubbing the hands together until they are dry.

Instruct the UAP to return to the client's room to perform handwashing.

Supervise the UAP in the next client's room to evaluate hand hygiene.

Advise the UAP to wear gloves when obtaining vital signs for all clients.

Answer and Explanation

The Correct Answer is A

A.   Reminding the UAP to continue rubbing the hands together until they are dry ensures proper use of the hand rub, which is effective when fully dry.
B.   Handwashing with soap and water is necessary after certain activities (e.g., after using the restroom, or when hands are visibly soiled), but using an alcohol-based hand rub is appropriate for routine hand hygiene.
C.   Supervising in the next client's room is less direct and immediate than ensuring proper technique now.
D.   Wearing gloves for all clients is not necessary and does not replace proper hand hygiene.

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Correct Answer is A

Explanation

A. Scoliosis is a lateral curvature of the spine. It is commonly assessed during routine physical examinations, especially in adolescents.
B. Lordosis refers to an exaggerated inward curvature of the spine, typically in the lumbar region.
C. Torticollis is a condition characterized by a tilt of the head to one side due to the shortening of muscles on one side of the neck.
D. Kyphosis is an exaggerated outward curvature of the thoracic spine, leading to a rounded upper back.

A. Report when hematuria becomes pink tinged. B. Restrict all physical activities. C. Use the incentive spirometer. D. Monitor urinary stream for decreased output.

Correct Answer is D

Explanation

A. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.

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The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?

Correct Answer is A

Explanation

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

Correct Answer is D

Explanation

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record?

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