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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Capillary refill time is 2 seconds is within the normal range and is unlikely to interfere with the pulse oximeter reading.

B. 2+ edema of fingers and hands most likely contributes to the low oxygen saturation reading. Edema can impair the accuracy of a pulse oximeter by affecting the transmission of light through the tissues, leading to erroneous readings.

C. Blood pressure is 142/88 mm Hg is mildly elevated but does not directly affect the pulse oximeter's ability to measure oxygen saturation.

D. Radial pulse volume is 3+ indicates a strong pulse and does not interfere with the functionality of the pulse oximeter.

A. Place the wheelchair on the client's left side. B. Instruct the client to take slow, deep breaths while transferring. C. Instruct the client to look at his feet. D. Have the client put both arms around the nurse's neck for support.

Correct Answer is A

Explanation

A. Place the wheelchair on the client's left side is the most appropriate action. Since the client has right-sided hemiplegia, the nurse should place the wheelchair on the client's left side to allow for easier transfer. The left side is the stronger side, and the client will be able to use this side to assist with the transfer.

B. Instruct the client to take slow, deep breaths while transferring may help with relaxation, but it is not the priority in this scenario. The focus should be on positioning and safety during the transfer.

C. Instruct the client to look at his feet is not advisable because it may disrupt the client's balance or lead to a fall. The client should focus on using the stronger side to assist with the transfer.

D. Have the client put both arms around the nurse's neck for support is not safe and could cause strain or injury to both the client and the nurse. The client should be instructed to use proper body mechanics and rely on the nurse for support during the transfer, but not in a way that could lead to injury.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

Correct Answer is A

Explanation

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A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

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