A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Remove the gloves.

Remove the mask.

Remove the protective eyewear

Remove the gown.

Answer and Explanation

The Correct Answer is A,CD,B

The nurse should first remove gloves to avoid contaminating other areas of the personal protective equipment. Afterward, the protective eyewear can be removed, followed by the gown, which may be contaminated, and finally, the mask should be removed last to minimize the risk of exposure to respiratory droplets.

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Correct Answer is D

Explanation

A. Kussmaul respirations are characterized by deep, rapid breathing typically associated with metabolic acidosis, not alternating periods of hyperventilation and apnea.

B. Apneustic respirations involve prolonged inspiration and shorter expiration phases, usually seen in brain injuries, but do not reflect alternating hyperventilation and apnea.

C. Stridor is a high-pitched wheezing sound indicative of upper airway obstruction, which does not describe the breathing pattern in this scenario.

D. Cheyne-Stokes respirations are defined by alternating periods of deep, rapid breathing (hyperventilation) followed by periods of no breathing (apnea), making this the correct choice for the client’s described pattern.

A. Check residual volume every 4 to 6 hr. B. Observe client's respiratory status. C. Elevate the head of the client's bed 30° to 45°. D. Monitor intake and output every 8 hr.

Correct Answer is C

Explanation

A. Checking residual volume is important for assessing tolerance to feedings, but it is not the priority action to prevent complications related to decreased consciousness.

B. Observing the client’s respiratory status is crucial but not the priority action related to enteral feedings.

C. Elevating the head of the client's bed 30° to 45° is the priority action, as it reduces the risk of aspiration during enteral feeding, which is a significant concern for clients with decreased consciousness.

D. Monitoring intake and output is important for overall assessment but is not the immediate priority in this context.

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A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is C

Explanation

The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take?

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