The nurse discusses and demonstrates proper hand hygiene to an immunocompromised patient and his wife. Which statement indicates a need for additional teaching?
a. "It is okay for my wife to wear artificial nails as long as she washes her hands properly."
b. "I should always wash my hands before I eat."
c. "Hand gels work as well as handwashing under most circumstances."
d. "I should use friction and wash my hands for about 20 seconds if I am using soap and water."
A
Artificial nails harbor microorganisms regardless of good hand hygiene. Washing hands prior to eating is good practice, as well as using friction and washing for 15 to 30 seconds with soap and water. Hand gels are effective in most circumstances except for certain infections such as C. dif-ficile and C. albicans.
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The nurse is assisting as a neurosurgeon examines a patient who has a positive Babinski reflex. What assessment finding would the nurse expect to observe?
a. The leg flexes when the patellar tendon is struck. b. The leg extends when the patellar tendon is struck. c. Toes curl downward when the sole of the foot is stroked. d. The big toe extends when the sole of the foot is stroked.
The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is cool and moist, and the respirations are 32 and shallow. These are signs of:
a. hypoglycemic reaction; give 6 oz of orange juice. b. hyperglycemic reaction; give ordered regular insulin. c. hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon gel in buccal cavity. d. hypoglycemic reaction; give ordered insulin.
When a patient in respiratory isolation is to be transported to the radiology department, the nurse should:
a. cover the patient with a sheet. b. take the patient down the service elevator. c. apply a mask to the patient. d. call x-ray to come and get the patient.
A nursing student correctly identifies which body system as being associated with most of the adverse effects of antiemetics?
A) Renal B) Central nervous system (CNS) C) Cardiovascular D) Integumentary