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 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.
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.