A nurse is caring for a client who is on isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first?

Gown

Mask

Eyewear

Gloves

Answer and Explanation

The Correct Answer is D

Rationale:

A. Gown: The gown should be removed after the gloves because it may be contaminated but has less direct contact with infectious material. Removing it after gloves helps reduce the risk of spreading pathogens from the hands to the clothing or environment.

B. Mask: The mask is usually removed last to prevent inhalation of airborne or droplet contaminants during PPE removal. Premature removal may expose the nurse to infectious particles still present in the surrounding air.

C. Eyewear: Goggles or face shields should be removed after gloves to avoid contamination of the face during removal. Touching the eyewear with potentially contaminated gloves could transfer pathogens close to the eyes or face.

D. Gloves: Gloves are the most contaminated PPE item due to direct patient contact and should be removed first. This limits the risk of transferring pathogens from the gloves to other PPE or surfaces during the removal process.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Rationale:
• Suicidal ideation: The client has a history of suicidal threats and is currently expressing distress, isolation, and a desire to no longer exist. These are key red flags for suicidal thoughts and require immediate monitoring.

• Hopelessness: Statements like “I wish I weren’t here” and “my life is a mess” indicate a loss of hope about the future. Hopelessness is a strong predictor of suicidal intent in clients with depression.

• Acute stress disorder: This condition involves exposure to a traumatic event within the past month with symptoms like flashbacks or dissociation. The client’s distress stems from life changes, not acute trauma.

• Borderline personality disorder: While this disorder includes unstable relationships and emotional reactivity, there is no history of impulsivity or identity disturbance to support the diagnosis.

• Emotional lability: The client displays a flat affect and tearfulness, not rapid mood shifts. Emotional lability refers to quick and exaggerated changes in emotional expression.

• Hypervigilance: This involves a heightened state of alertness often associated with trauma or PTSD. The client’s behavior is more aligned with withdrawal and depression.

A. Use an N95 respirator. B. Initiate contact precautions C. Place the child in a room that has a HEPA filtration system. D. Instruct the parents to avoid bringing fresh flowers into the room.

Correct Answer is B

Explanation

Rationale:

A. Use an N95 respirator: N95 respirators are necessary for airborne precautions, such as with tuberculosis or measles. C. difficile is transmitted via contact with contaminated surfaces or stool, not airborne particles, so an N95 is not indicated.

B. Initiate contact precautions: Contact precautions are required for C. difficile because it spreads through direct and indirect contact with contaminated surfaces or stool. Gloves and gowns should be worn, and hand hygiene with soap and water is essential to prevent spore transmission.

C. Place the child in a room that has a HEPA filtration system: HEPA filters are used for airborne pathogens or immunocompromised clients, not for enteric infections like C. difficile. This intervention would not reduce transmission risk in this case.

D. Instruct the parents to avoid bringing fresh flowers into the room: This precaution is typically for neutropenic or immunocompromised clients to reduce exposure to potential fungal spores. C. difficile precautions focus on containment of fecal-oral transmission routes, not environmental fungal sources.

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A nurse is caring for a client who is on isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is assisting with the care of a client. Exhibits Complete the following sentence by using the lists of options. The client is at risk for dropdown as evidenced by the client’sdropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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Correct Answer is B

Explanation

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