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 A
Explanation
A. Removing blankets from the client helps reduce external heat sources and allows body heat to dissipate, which can aid in lowering the elevated temperature. This action supports the body’s natural cooling mechanisms and provides comfort during a febrile state.
B. Placing cold packs on the axillae can help lower body temperature by cooling major blood vessels near the skin’s surface. However, this method may cause discomfort or shivering, which can paradoxically increase metabolic heat production and is less preferred than removing excess coverings.
C. Using a fan to blow air across the client promotes evaporative cooling, but if the client is shivering or chills are present, this can increase discomfort and cause the body to generate more heat. Fans are best used when the client is comfortable and not experiencing chills.
D. Giving an alcohol sponge bath is generally discouraged because alcohol is rapidly absorbed through the skin and can cause toxicity. Additionally, it can cause vasodilation, which might lead to increased heat loss and potential hypothermia if not carefully monitored.
Correct Answer is D
Explanation
A. Increase in protein requirements: Protein needs may slightly increase with age to maintain muscle mass, but this does not directly cause weight gain. Instead, inadequate protein may contribute to muscle loss.
B. Increase in fluid requirements: Older adults typically have decreased thirst sensation, not increased fluid needs. Weight gain is not directly linked to hydration needs but more to energy balance.
C. Decrease in vitamin intake: While older adults may have reduced vitamin intake due to dietary changes, this affects micronutrient status rather than causing significant weight gain.
D. Decrease in muscle mass: Sarcopenia, the loss of muscle mass with aging, lowers basal metabolic rate. This decreases calorie expenditure, making it easier to gain weight even with unchanged food intake.
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