A nurse is leaving a client's isolation room. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?
Gloves.
Goggles.
Gown.
Mask.
The Correct Answer is A
Choice A rationale:
When leaving a client's isolation room, the nurse should remove gloves (Choice A) first. Gloves are considered contaminated and can harbor microorganisms. Removing them first helps prevent the spread of potential pathogens to other surfaces or items while removing other personal protective equipment (PPE).
Choice B rationale:
Goggles (Choice B) protect the eyes from splashes and airborne particles. However, they should be removed after gloves. Gloves have a higher potential for contamination due to direct contact with the client and the environment.
Choice C rationale:
Removing the gown (Choice C) should follow the removal of gloves and goggles. The gown provides a barrier against potential contaminants and should be taken off to prevent self-contamination while disrobing from other PPE.
Choice D rationale:
The mask (Choice D) should be removed last. It provides respiratory protection and prevents the nurse from inhaling airborne particles. Keeping the mask on while removing other PPE items helps maintain a barrier against potential exposure to respiratory pathogens.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Planning to insert an oral airway if seizure activity begins is not a suitable intervention for a client with a history of seizures. During a seizure, it's essential to protect the client from injury by preventing them from aspirating secretions or foreign objects. However, inserting an oral airway during an active seizure can be dangerous and lead to injury.
Choice B rationale:
Administering pain medication after the seizure is not a priority intervention. While some clients may experience muscle soreness or discomfort following a seizure, the primary focus during and immediately after a seizure is ensuring the client's safety and preventing injury. Pain medication can be considered later if necessary.
Choice C rationale:
The correct choice is to pad the side rails of the client's bed with blankets. This intervention aims to prevent injury if the client experiences a seizure and comes into contact with the bed rails. Padding the side rails can reduce the risk of trauma and minimize the potential for harm during a seizure episode.
Choice D rationale:
Placing the client in a supine position during a seizure is not recommended. It's important to position the client on their side (lateral recumbent position) during a seizure to allow any oral secretions or vomit to drain from the mouth, reducing the risk of aspiration. Placing the client supine could obstruct the airway and increase the risk of aspiration.
Correct Answer is A
Explanation
Choice A rationale: Selecting a site at least 5 cm (2 in) away from the umbilicus is essential because the tissue around the navel is often tougher and has altered vascularity, which can lead to inconsistent medication absorption.
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Choice B rationale: Air bubbles in prefilled syringes, such as those used for enoxaparin, should not be expelled. The air bubble is designed to be injected last to seal the medication within the subcutaneous tissue and prevent leakage.
Choice C rationale: Aspiration is no longer recommended for subcutaneous injections. There are no large blood vessels in the subcutaneous layer, and aspiration increases the risk of tissue trauma, hematoma formation, and client discomfort.
Choice D rationale: Subcutaneous injections should be administered at a 45° to 90° angle, depending on the amount of subcutaneous fat available. A 15° angle is used specifically for intradermal injections, such as TB skin tests.
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