A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

Gloves

Gown

Eyewear

Mask

Answer and Explanation

The Correct Answer is D

Choice A reason: Gloves are typically removed first because they are likely to be the most contaminated. They should be removed carefully to avoid contaminating the hands, using the glove-in-glove or beak method.

Choice B reason: The gown should be removed after the gloves because it may also be contaminated. The nurse should reach up to the shoulders and carefully pull the gown forward and away from the body, touching only the inside of the gown.

Choice C reason: Eyewear is removed after the gown. The nurse should handle the eyewear by the arms, avoiding touching the front part that has been exposed to contaminants.

Choice D reason: The mask should be removed last because it protects the mucous membranes of the mouth and nose from infectious droplets. It should be taken off by handling the ties or elastic bands from behind the head and pulling it away from the face without touching the front of the mask.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason: Expecting the client to express pain both verbally and nonverbally is important in postoperative care. Pain expression is subjective and can vary greatly among individuals. Some clients may verbalize their discomfort, while others may exhibit nonverbal cues such as grimacing, restlessness, or guarding the affected area. It is crucial for nurses to be attentive to all forms of pain expression to assess and manage the client's pain effectively.

Choice B reason: Administering opioids with caution is a standard practice due to the risk of addiction; however, the statement that they will eventually lead to addiction is misleading. Opioids, when used appropriately and under medical supervision, are an effective component of postoperative pain management. The risk of addiction is present but can be mitigated through careful monitoring, patient education, and using the lowest effective dose for the shortest duration necessary.

Choice C reason: Administering analgesics orally for fast-acting pain relief is a common practice, especially when immediate onset is not required. Oral administration is non-invasive and convenient, but it is not the fastest method for pain relief compared to intravenous administration. The choice of analgesic and the route of administration should be based on the client's pain level, type of surgery, and individual needs.

Choice D reason: Using a pain scale from 0 to 10 is an effective way to monitor the severity of the client's pain. This method provides a quantifiable measure of pain intensity, allowing for consistent assessment and facilitating communication between the client and healthcare providers. It helps in evaluating the effectiveness of pain management interventions and in making necessary adjustments to the pain management plan.

Choice E reason: Considering the client's individual expression of pain is essential in postoperative care. Pain is a personal experience, and what may be tolerable for one person could be unbearable for another. Factors such as cultural background, previous pain experiences, psychological state, and the presence of comorbidities can influence pain perception. Tailoring pain management strategies to the individual's needs and preferences is key to effective pain control.

A. Carotid B. Popliteal C. Femoral D. Brachial

Correct Answer is A

Explanation

Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.

Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.

Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.

Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.

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A nurse caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of personal protective equipment (PPE) should the nurse remove last?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following should apply? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

Correct Answer is A

Explanation

A nurse is monitoring a postoperative client who is unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client is experiencing pain? (Select all that apply)

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