A nurse has just finished a wound care procedure for a client. Which of the following should the nurse remove first?

Goggles

Gloves

Mask

Gown

Answer and Explanation

The Correct Answer is B

A. Goggles: Goggles protect the eyes from splashes and should be removed after gloves and gown, once the risk of contamination is lower. Removing them too early can increase the risk of contamination if hands are still contaminated.

B. Gloves: Gloves are the most contaminated item after wound care and should be removed first to prevent spreading microorganisms to other personal protective equipment or the nurse’s skin. Proper glove removal technique reduces the risk of self-contamination.

C. Mask: Masks protect the respiratory tract and are typically removed last, after gloves, gown, and goggles, to maintain protection as long as possible. Removing the mask too early can expose the nurse to airborne particles.

D. Gown: The gown is removed after gloves because it is also contaminated but less so than gloves. Removing gloves first minimizes transferring contaminants from the gloves to the gown or other surfaces during removal.

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Correct Answer is A

Explanation

A. "He is allergic to sulfa." Communicating a client’s allergies during transfer is critical to ensure patient safety and prevent adverse reactions. This information directly impacts medication administration and care planning on the receiving unit, making it essential to include in the transfer report.

B. "His partner has been visiting." While family involvement can be helpful, details about visitors are generally less urgent and not typically necessary in a transfer report unless they directly affect the client’s care or safety.

C. "He appears anxious about the transfer." Emotional status is important but is secondary to clinical information. If anxiety significantly affects the client’s care or safety, it might be mentioned, but it is not a priority in a transfer report focused on immediate clinical needs.

D. "He is voiding adequately." Although voiding status is relevant to some clients’ care, it is less critical than allergy information unless the client has a specific condition affecting urinary function that requires close monitoring. The allergy detail remains a higher priority in transfer communication.

A. Measure the intake and output of a client who has received furosemide. B. Check a client's peripheral IV site for redness or swelling. C. Assess the pain level of a client who has received acetaminophen. D. Reinforce teaching with a client about crutch-gait walking.

Correct Answer is A

Explanation

A. Measure the intake and output of a client who has received furosemide: Measuring intake and output is within the scope of practice for assistive personnel. The nurse remains responsible for interpreting the data and notifying the provider of any concerns.

B. Check a client's peripheral IV site for redness or swelling: Assessment of IV sites for complications such as infiltration, phlebitis, or infection requires clinical judgment and should be performed by licensed nursing personnel.

C. Assess the pain level of a client who has received acetaminophen: Pain assessment requires clinical judgment, interpretation of client responses, and knowledge of pain scales. Only licensed nurses should perform pain assessments and determine the effectiveness of interventions.

D. Reinforce teaching with a client about crutch-gait walking: Reinforcing teaching involves understanding and communicating clinical concepts accurately. Even though it may seem routine, instructing or clarifying a gait technique requires nursing knowledge to ensure client safety and proper technique.

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A nurse has just finished a wound care procedure for a client. Which of the following should the nurse remove first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is A

Explanation

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is A

Explanation

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