A nurse is leaving a client's isolation room. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

The correct answer is Choice A.

Choice A rationale: Administering enoxaparin 40 mg subcutaneously in the deltoid site is incorrect. Enoxaparin is typically administered in the abdomen or thigh to ensure proper absorption and minimize the risk of injury. Administering it in the deltoid requires an incident report for protocol deviation.

Choice B rationale: Advancing the urinary catheter 18 cm (7 in) is standard practice for male clients to ensure the catheter reaches the bladder. There is no indication of error or the need for an incident report as this action follows proper procedure.

Choice C rationale: Cleansing a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture is standard practice. This action ensures the wound is free from surface contaminants and does not necessitate an incident report.

Choice D rationale: Flushing the tubing of a continuous enteral feeding with 30 mL of water is standard practice to maintain patency and ensure the effectiveness of the feeding. This procedure follows guidelines and does not require an incident report.

Choice A rationale:

Instructing the client to remain supine for 10 minutes after inserting a vaginal suppository helps ensure proper absorption of the medication. This position allows the suppository to stay in contact with the vaginal mucosa, promoting optimal drug absorption. This is an essential nursing action to maximize the therapeutic effect of the medication.

Choice B rationale:

Applying sterile gloves after cleansing the perineal area is not necessary when administering a vaginal suppository. While maintaining cleanliness is important, the use of sterile gloves is not typically required for this procedure. Clean, non-sterile gloves are sufficient to maintain aseptic technique during the administration.

Choice C rationale:

Inserting the suppository 3 to 4 cm (1 to 1.5 in) into the vagina is an appropriate depth for vaginal suppository insertion. The nurse should follow this guideline to ensure that the medication reaches the appropriate location within the vaginal canal, optimizing absorption and effectiveness.

Choice D rationale:

Placing the client in the lateral semi-prone recumbent position is not a standard position for administering a vaginal suppository. The suppository is typically administered with the client lying on their back (supine) to facilitate insertion and medication absorption. Placing the client in the position described would not provide the optimal angle for insertion.