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."
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 D
Explanation
A. While completing an incident report is important for documentation and quality improvement, it is not the immediate priority in the event of a medication error.
B. Notifying the nurse manager is a necessary step for reporting the error, but it should occur after ensuring the client's safety.
C. Calling the client's provider is essential to discuss the medication error and possible interventions, but the client's health and safety must be assessed first.
D. Assessing the client is the priority action to ensure the client’s safety and to identify any adverse effects resulting from the wrong medication. The nurse needs to determine the client's vital signs, level of consciousness, and any immediate symptoms related to the medication administered.
Correct Answer is D
Explanation
A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.
B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.
C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.
D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.