A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products.

The child has a chemical smell on their hands, face, and clothes.
After ensuring the airway is patent, which action should the nurse take first?

The correct answer is choiceB. Confirm that the gown is tied securely at the neck and waist.

Choice A rationale:

Reminding the UAP to wash hands frequently while in the room is important for infection control, but it is not the immediate priority in this scenario. The UAP has already donned gloves, which are part of the personal protective equipment (PPE) required for contact precautions. Hand hygiene is crucial before and after patient contact and after removing gloves, but ensuring the gown is properly secured takes precedence to prevent contamination.

Choice B rationale:

Confirming that the gown is tied securely at the neck and waist is essential to ensure that the UAP is fully protected from potential contamination.A properly secured gown prevents the UAP’s clothing from coming into contact with the patient or contaminated surfaces, which is critical in maintaining effective contact precautions.

Choice C rationale:

Assisting the UAP with the application of a face mask or face shield is necessary for droplet or airborne precautions, not specifically for contact precautions.Since the scenario involves contact precautions, the focus should be on the gown and gloves.

Choice D rationale:

Helping the UAP reposition the gown sleeve over the glove edges is not necessary because the UAP has already secured the tops of the gloves over the gown sleeves.This method is appropriate as it prevents the sleeves from becoming contaminated.

Choice A rationale
While any positive response on the CAGE questionnaire could be a cause for concern and warrant further investigation, one positive response does not definitively indicate that the patient should seek help with alcohol addiction. The CAGE questionnaire is a screening tool used to identify potential problems with alcohol, but it is not diagnostic. A healthcare provider would need to conduct a more thorough assessment to diagnose alcohol addiction.
Choice B rationale
It is not necessary for all responses to the CAGE questionnaire to be positive in order to suggest alcohol dependence. The CAGE questionnaire is a screening tool, and while a greater number of positive responses increases the likelihood of alcohol dependence, it is not a requirement for all responses to be positive. A score of two or more is considered clinically significant.

Choice C rationale
The CAGE questionnaire is indeed a tool used to identify potential problems with alcohol, but it is not used to identify general substance abuse. The CAGE questionnaire specifically asks about feelings related to alcohol use. There are other screening tools available that are designed to identify issues with other substances.
Choice D rationale
This is the correct answer. The CAGE questionnaire is a validated screening tool that is widely used in clinical settings to detect alcoholism. It is considered positive, and suggestive of alcohol dependence, if two or more questions are answered affirmatively.