A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

A client who has dehydration with a urine output of 40 mL/hr.

A client who has cancer and reports pain as 4 on a scale of 0 to 10.

A client who has asthma and a respiratory rate of 40/min.

A client who has diabetes mellitus and a fasting blood glucose of 100 mg/dL.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Dehydration is a serious condition, and a urine output of 40 mL/hr is indicative of decreased renal perfusion and potential renal failure. However, this situation does not require immediate intervention compared to other choices.

Choice B rationale:

Pain management is important, and a pain score of 4 out of 10 indicates mild to moderate pain. While addressing pain is essential for the client's comfort, it is not an immediate priority compared to the situation presented in another choice.

Choice C rationale:

(Correct Choice) A respiratory rate of 40 breaths per minute in a client with asthma indicates severe respiratory distress. This client is at risk of respiratory failure and requires immediate assessment and intervention.

Choice D rationale:

A fasting blood glucose of 100 mg/dL in a client with diabetes mellitus is within a normal range and does not require immediate attention when compared to the urgent situation in another choice.

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Correct Answer is A

Explanation

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.

A. "I will clean reusable equipment with isopropyl alcohol before removing it from the client's room.". B. "I will clean my hands with alcohol-based hand sanitizer after removing the client from the bedpan.". C. "I will wear a mask when I am within 3 feet of the client.". D. "I will wear gloves when changing the client's hospital gown.".

Correct Answer is D

Explanation

The correct answer is choiced. “I will wear gloves when changing the client’s hospital gown.”

Choice A rationale:

Cleaning reusable equipment with isopropyl alcohol is not effective against Clostridium difficile spores. Equipment should be cleaned with a sporicidal disinfectant to ensure the removal of C.difficile spores.

Choice B rationale:

Alcohol-based hand sanitizers are not effective against C. difficile spores.Hand hygiene should be performed with soap and water after contact with the client or their environment.

Choice C rationale:

Wearing a mask within 3 feet of the client is not necessary for C. difficile infection, as it is not transmitted via respiratory droplets.The primary mode of transmission is through contact with contaminated surfaces or feces.

Choice D rationale:

Wearing gloves when changing the client’s hospital gown is essential to prevent the transmission of C. difficile spores.Gloves should be worn for all contact with the client or their environment

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A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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