A nurse has just finished a wound care procedure for a client. Which of the following should the nurse remove first?

Goggles

Gloves

Mask

Gown

Answer and Explanation

The Correct Answer is B

A. Goggles: Goggles protect the eyes from splashes and should be removed after gloves and gown, once the risk of contamination is lower. Removing them too early can increase the risk of contamination if hands are still contaminated.

B. Gloves: Gloves are the most contaminated item after wound care and should be removed first to prevent spreading microorganisms to other personal protective equipment or the nurse’s skin. Proper glove removal technique reduces the risk of self-contamination.

C. Mask: Masks protect the respiratory tract and are typically removed last, after gloves, gown, and goggles, to maintain protection as long as possible. Removing the mask too early can expose the nurse to airborne particles.

D. Gown: The gown is removed after gloves because it is also contaminated but less so than gloves. Removing gloves first minimizes transferring contaminants from the gloves to the gown or other surfaces during removal.

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Correct Answer is D

Explanation

A. Locks the wheelchair after transferring the client: Locking the wheelchair should occur before the transfer to prevent it from rolling during the movement. Locking it after transferring compromises client safety and increases the risk of falls or injury.

B. Places the bed in a high position before transferring the client to the wheelchair: The bed should be placed in the lowest safe position to allow the client’s feet to touch the floor and to ease the transition to a lower surface like a wheelchair. A high bed position creates an unsafe height differential.

C. Uses a narrow stance when assisting the client to the wheelchair: A wide stance provides a stronger, more stable base of support, which is essential for safe body mechanics during a transfer. A narrow stance can lead to imbalance and injury to the AP or client.

D. Positions the wheelchair parallel to the client's bed: Positioning the wheelchair parallel or at a slight angle to the bed allows for easier and safer transfers. This minimizes turning and supports a smoother pivot, reducing strain on both the client and caregiver.

A. Brittle hair B. Yellow conjunctivae C. Bradycardia D. Clubbing of the fingernails

Correct Answer is A

Explanation

A. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.

B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.

C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.

D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.

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A nurse has just finished a wound care procedure for a client. Which of the following should the nurse remove first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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