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 C

Explanation

A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

A. Turn on loud music in client care areas. B. Assign different nurses to provide care for clients each day. C. Restrict the number of visitors for clients. D. Offer the clients many choices regarding care.

Correct Answer is C

Explanation

A. Turn on loud music in client care areas: Loud music can increase noise levels, which contributes to environmental stress and can disrupt clients’ rest and recovery. It is generally contraindicated in acute care settings where reducing stress and promoting healing are priorities.

B. Assign different nurses to provide care for clients each day: Frequent changes in caregivers can increase client anxiety and stress by reducing continuity of care and trust. Consistent assignments promote familiarity, comfort, and better communication between clients and caregivers.

C. Restrict the number of visitors for clients: Limiting visitors helps reduce noise and overcrowding, which are common environmental stressors in acute care units. This strategy supports a calmer environment conducive to client rest and recovery while maintaining essential social support.

D. Offer the clients many choices regarding care: While offering choices can promote autonomy, providing too many options may overwhelm clients, especially those who are ill or stressed. Simplifying decisions helps reduce cognitive overload and environmental stress.

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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

A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

Correct Answer is C

Explanation

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

Correct Answer is C

Explanation

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