A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first?

Gloves

Mask

Gown

Goggles

Answer and Explanation

The Correct Answer is A

A. Gloves: When removing PPE for a client requiring airborne precautions, gloves should be removed first because they are considered the most contaminated item. Removing gloves first helps prevent contamination of other PPE and the healthcare provider's hands.

B. Mask: After removing gloves, the mask should be removed by grasping the ties or ear loops without touching the front of the mask. Removing the mask prevents the potential spread of infectious agents when the client is no longer in the immediate vicinity.

C. Gown: Following the removal of the mask, the gown should be removed, taking care to avoid touching the front of the gown. Removing the gown minimizes the risk of contamination to the healthcare provider's clothing or skin.

D. Goggles: If goggles were worn as part of the PPE for airborne precautions, they should be removed last after gloves, mask, and gown. Removing goggles last helps prevent any potential contamination of the eyes during the removal process.

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

Explanation

A) Increase hematocrit: Fluid overload typically results in dilutional effects on the blood, leading to a decrease in hematocrit rather than an increase. Hematocrit levels may decrease due to the relative decrease in the concentration of red blood cells in relation to plasma.

B) Increased temperature: Fluid overload is not typically associated with an increase in body temperature. While fever can occur as a result of infection, it is not a direct manifestation of fluid overload.

C) Increased heart rate: Fluid overload can lead to increased blood volume, which results in an increased workload for the heart. As a compensatory mechanism, the heart rate may increase to maintain adequate cardiac output.

D) Increased respiratory rate: Fluid overload can cause pulmonary congestion and impair gas exchange in the lungs, leading to respiratory distress. As a result, the respiratory rate may increase as the body attempts to compensate for the decreased oxygenation.

E) Increased blood pressure: Fluid overload can lead to an increase in blood volume, which results in increased pressure within the blood vessels. As a result, blood pressure may rise as the heart works harder to pump the excess fluid throughout the body.

A. The client's hand is cool and pale B. The client has full range of motion in her wrist C. The client is attempting to remove the restraint. D. The client has a capillary refill of less than 2 seconds.

Correct Answer is A

Explanation

A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.

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A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Correct Answer is A

Explanation

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