The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)
Don gloves.
Apply a surgical mask.
Put on an isolation gown.
Wash hands.
The Correct Answer is D,C,B,A
Correct order: D C B A
- Washing hands is the first step before any PPE is applied to ensure cleanliness and prevent the introduction of pathogens.
- Putting on the isolation gown is the next step, as it protects the nurse's clothing from exposure to potentially infectious materials.
- Applying a surgical mask is the next step to protect the nurse from airborne or droplet transmission.
- Donning gloves is the final step, as gloves should be put on last to protect the hands while providing direct care, especially when dealing with wound care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Explain that alternative treatment options may be helpful is not appropriate at this moment. The spouse is expressing grief, and the focus should be on emotional support rather than discussing medical treatment options, which may not be relevant to the spouse’s current emotional state.
B. Offer reassurance that the spouse is not alone may provide some comfort but does not address the underlying need for the spouse to express their emotions. It is more important to listen and allow the spouse to share their feelings first.
C. Encourage the spouse to share their feelings is the most appropriate first response. The spouse is expressing emotional distress, and the nurse should offer a safe space for the spouse to talk about their feelings. This approach helps to validate the spouse’s emotions and provides an opportunity for emotional support.
D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.
D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.
Correct Answer is D
Explanation
A. Restrict oral fluid intake is not appropriate in this situation. Decreased bowel sounds and constipation may indicate a need for hydration, not restriction of fluids. Fluids are essential to help prevent and alleviate constipation.
B. Offer to warm the prune juice may be helpful in some cases to encourage the client to drink, but it does not address the underlying issue of constipation and decreased bowel sounds. A more comprehensive intervention, such as bowel training, is needed.
C. Advance to a regular diet may not be appropriate without assessing the client's tolerance for additional food types. The client is on a mechanical soft diet, which may already be sufficient. Advancing to a regular diet could potentially exacerbate the constipation.
D. Initiate bowel training protocol is the most appropriate action. Bowel training is designed to help manage constipation and promote regular bowel movements. This may include dietary adjustments, increased fluid intake, and other measures such as scheduled toileting.
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