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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","A","C","D"]
Explanation
A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.
B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.
C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.
D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.
Correct Answer is D
Explanation
A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.
B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.
C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.
D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.
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