A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus.
When removing personal protective equipment, which of the following pieces should the nurse remove first?
Goggles.
Gown.
Mask.
Gloves.
The Correct Answer is D
The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.
The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.
The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.
Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.
Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.
Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.
Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).
Higher pressures may damage the wound tissue and increase the risk of infection.
Lower pressures may not be effective in removing debris and bacteria from the wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.
Choice A rationale:
Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.
Choice B rationale:
Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.
Choice C rationale:
Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.
Choice D rationale:
Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.
Correct Answer is C
Explanation
The correct answer is choice C. “I will assist you in any way I can during this process.” This response shows sensitivity and respect for the client’s family and their cultural or religious beliefs. Postmortem care involves caring for a deceased patient’s body with dignity and in a manner that is consistent with the patient’s and family’s wishes.The nurse should offer to assist the family in performing the postmortem care if they request to do so.
Choice A is wrong because the family does not need to sign a release form to perform the postmortem care themselves.
There is no legal requirement for this.
Choice B is wrong because a licensed health care worker does not have to perform postmortem care.
The family can perform the care themselves if they wish, with or without the assistance of a health care worker.
Choice D is wrong because postmortem care takes place before the client leaves the facility, not after.
Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement.
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