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","B","C","E"]

Explanation

Choice A reason: Restlessness can be a sign of discomfort or pain, especially in a postoperative client. It may manifest as constant shifting or an inability to remain still, indicating that the client is trying to find a position that alleviates the pain.

Choice B reason: Clenching, such as tightly gripping the handrails of the bed or making fists, can indicate that the client is trying to manage pain or discomfort through tension in the muscles.

Choice C reason: Grimacing, or making a pained facial expression, is a clear nonverbal cue of pain. It often involves furrowing the brow, closing the eyes tightly, or contorting the mouth.

Choice D reason: Drowsiness is not typically a direct indicator of pain. It may be related to medication effects, fatigue, or the body's response to healing post-surgery. However, it does not specifically signal pain.

Choice E reason: Moaning, groaning, or making other vocal sounds can be a response to pain, particularly in clients who are unable to articulate their pain verbally due to sedation or other factors.

A. Airborne B. Droplet C. Protective environment D. Contact

Correct Answer is D

Explanation

Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.

Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.

Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.

Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.

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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 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)

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

Explanation

A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?

Correct Answer is D

Explanation

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

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