A nurse is collecting data from a client who has hyperparathyroidism and is receiving 0.9% sodium chloride via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

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.

Rationale:

A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.