Question

A nurse is preparing to apply personal protective equipment before caring for a client who requires isolation precautions. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Answer 1

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

✅ Step 1: Put on a gown

🧥 The gown is applied first because it provides a protective barrier that covers the nurse’s skin and clothing.

🧥 It must fully cover the torso and arms, and be tied securely at the neck and waist.

🧥 This step reduces the risk of contamination from body fluids or infectious droplets contacting the uniform.

🧥 Starting with the gown ensures that all subsequent PPE is placed on top, maintaining a secure protective layer.

🧥 Proper gown use prevents cross-contamination between patient and environment.

✅ Step 2: Don a mask

😷 The mask is applied before other facial protective equipment to protect the respiratory tract from inhalation of infectious droplets or airborne pathogens.

😷 The nurse must ensure the mask fits snugly over the nose and mouth with no gaps.

😷 For airborne precautions, an N95 respirator or higher-level mask may be required.

😷 Placing it at this stage avoids contamination from handling the mask after gloves or goggles are on.

😷 This step prevents respiratory exposure to infectious agents.

✅ Step 3: Put on goggles

🥽 Goggles (or a face shield) protect the mucous membranes of the eyes from splashes, sprays, and droplets.

🥽 Eye protection is especially critical when caring for patients with infections that spread through body fluids or procedures that generate aerosols.

🥽 They should fit comfortably and securely, covering the eyes completely.

🥽 Goggles are placed after the mask to ensure both pieces of facial protection are properly fitted.

🥽 This step adds a second layer of defense for exposed facial areas.

✅ Step 4: Don gloves

✋ Gloves are applied last because they provide direct hand protection against contact with infectious materials.

✋ Gloves should extend over the cuffs of the gown to create a complete barrier.

✋ Placing gloves last prevents contamination of other PPE items while they are being donned.

✋ Gloves must be changed between tasks and patients to prevent cross-contamination.

✋ This final step ensures the nurse is fully protected before beginning patient care.

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Answer 2

Correct Answers:

Cheese

Rationale :

💎 A lacto-vegetarian diet includes dairy products (milk, cheese, yogurt, butter) but excludes meat, poultry, seafood, and eggs.

💎 Cheese is appropriate because it provides protein and calcium while fitting within lacto-vegetarian guidelines.

💎 Tuna fish, chicken, and clam chowder are not permitted, since they involve animal flesh (fish, poultry, or shellfish).

💎 Nurses should reinforce patient education on plant-based sources of protein (beans, lentils, soy products) and calcium (dairy, fortified plant milks, leafy greens).

💎 This ensures the patient maintains a balanced diet without violating their dietary preferences.

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Answer 3

Correct Answers:

Discussing a client's treatment plan at the nurses' station

Rationale :

💎 HIPAA (Health Insurance Portability and Accountability Act) protects the privacy and confidentiality of patient health information.

💎 Discussing a client’s treatment plan at the nurses’ station, where unauthorized individuals (visitors, other patients, non-care staff) might overhear, is a violation of HIPAA.

💎 Sharing patient status with the nurse who will assume care is appropriate because it ensures continuity of care.

💎 Discussing care with the patient’s legal guardian is also appropriate, as guardians are authorized to receive health information.

💎 Allowing patients access to their own medical records is a legal right under HIPAA, not a violation.

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Answer 4

Correct Answers:

"You are feeling angry that your family continues to wish for a cure?"

Rationale :

💎 This response uses therapeutic communication by reflecting the client’s feelings, which validates their emotions and encourages further expression.

💎 It shows empathy and understanding without judgment, helping the client feel heard during a difficult stage of their illness.

💎 Responses that sound judgmental, dismissive, or redirective (like suggesting they have “given up” or pushing them to talk about anger prematurely) do not promote open communication.

💎 The nurse’s role in hospice care is to provide emotional support, comfort, and presence, allowing the client to share fears and frustrations.

💎 This approach helps the nurse explore the patient’s emotional and psychosocial needs while building trust.

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Answer 5

Correct Answers:

Request a chest x-ray

Rationale :

💎 The most reliable method to verify feeding tube placement is a chest/abdominal x-ray. This ensures the tube is in the stomach or small intestine, not in the respiratory tract.

💎 While checking pH of gastric aspirate can help, it is not as accurate as radiographic confirmation, especially in patients on acid-suppressing medications.

💎 Auscultating for air insufflation (the “whoosh test”) is not reliable and is no longer recommended because it cannot rule out misplacement in the lungs or esophagus.

💎 Measuring bilirubin in aspirate is not a standard or reliable method for confirming placement.

💎 Since misplaced tubes can cause serious complications such as aspiration pneumonia or lung injury, an x-ray remains the gold standard for safe practice.

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Answer 6

Correct Answers:

Pad bony prominences before applying a restraint.
Ensure that 2 fingers can be placed between the restraint and the client

Rationale :

✅ Pad bony prominences before applying a restraint

🟢 Protects fragile skin: Older adults in long-term care facilities often have thin, delicate skin that is prone to breakdown. Padding reduces direct pressure from the restraint against bony areas like the wrists, ankles, and elbows.

🟢 Prevents complications: Without padding, restraints can cause bruising, abrasions, or even skin tears. Over time, continuous pressure in these areas can result in pressure ulcers or impaired skin integrity.

🟢 Supports circulation: Padding helps reduce excessive pressure on blood vessels, which could otherwise compromise circulation and increase the risk of swelling or tissue injury.

🟢 Enhances comfort: Adding padding improves the client’s overall comfort, making the restraint less restrictive and more tolerable. This aligns with nursing’s ethical responsibility to minimize harm and preserve dignity.

🟢 Demonstrates best practice: By padding, nurses follow restraint safety guidelines that emphasize balancing client safety with comfort while reducing harm.

✅Ensure that 2 fingers can be placed between the restraint and the client

🔵 Prevents overly tight application: Restraints applied too tightly can cut off circulation, cause numbness, tingling, or nerve injury. The “two-finger rule” provides a standard for safe, effective restraint placement.

🔵 Promotes blood flow: Allowing space between the restraint and the skin ensures that blood can continue to circulate freely, preventing ischemia, edema, or permanent nerve damage.

🔵 Maintains effectiveness without risk: Restraints should be secure enough to prevent removal, but not so tight that they pose danger. The two-finger guideline achieves this balance.

🔵 Facilitates regular monitoring: Nurses can quickly check restraint fit during assessments to confirm the device is both effective and safe. This reinforces the practice of frequent monitoring required by safety standards.

🔵 Supports client dignity: Proper application shows respect for the client’s comfort while maintaining safety, an essential aspect of ethical nursing care.

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Answer 7

Correct Answers:

mcg

Rationale :

✔️mcg is the safe and recommended abbreviation for micrograms. It reduces the risk of medication errors compared to using “µg,” which could be mistaken for “mg” (milligrams). Clear, standardized abbreviations are part of safe medication practices.

✔️sub q is not acceptable because it can be misread as “SL” (sublingual) or “5 every.” Instead, nurses should write out “subcut” or “subcutaneously.”

✔️qhs (not “ghs”) is sometimes used to mean “every night at bedtime,” but it is discouraged because it can be misread as “qhr” (every hour). Best practice is to write “at bedtime.”

✔️god is not a recognized or safe abbreviation in medical transcription.

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Answer 8

Correct Answers:

"You should start receiving mammograms as early as age 40."

Rationale :

🔹 Mammograms beginning at age 40 are recommended for women at average risk (no family history or genetic predisposition). This imaging test helps detect breast cancer in its earliest stages, when treatment is most effective.

🔹 Guidelines from organizations such as the American Cancer Society (ACS) suggest that women aged 40–44 may choose annual mammograms, and women 45–54 should have them annually. From age 55 onward, women can continue yearly or switch to every 2 years based on preference and health status.

🔹 Mammography is more reliable than breast self-exams or ultrasounds for routine screening in the general population, as it can detect small tumors before they are palpable.

🔹 Emphasizing mammograms at age 40 empowers women to take a proactive role in their health and aligns with evidence-based early detection strategies.

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Answer 9

Correct Answers:

Collaborate with the RN to plan an interprofessional client care conference

Rationale :

🌐 Encourages team-based care: An interprofessional conference brings together the RN, physician, social worker, chaplain, and other specialists to ensure the family receives coordinated information and support.

🌐 Addresses holistic needs: This meeting allows the family to discuss the client’s medical, emotional, spiritual, and psychosocial concerns in one setting, reducing confusion and anxiety.

🌐 Promotes clear communication: Families often struggle with fragmented updates. A joint conference ensures that all providers deliver consistent and accurate guidance, helping the family make informed decisions.

🌐 Supports decision-making and coping: By including the family in the care planning process, the team validates their concerns, empowers them, and builds trust during the difficult end-of-life period.

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Answer 10

Correct Answers:

A client receives burns from a heating pad
A client becomes disoriented and falls out of bed
A client's visitor becomes dizzy and faints in the client's room.

Rationale :

🔥 Client receives burns from a heating pad

🔸 Reportable injury: Any device-related harm is an unexpected, adverse event that requires an incident report for safety tracking and risk management.

🔸 Immediate care + escalation: Remove the heat source, assess the burn (location, size, depth), check vital signs, provide first aid, and notify the provider.

🔸 Quality improvement: Document device brand, settings, placement, skin checks performed, and contributing factors (e.g., impaired sensation, cognitive status) to guide policy/equipment changes.

🔸 Prevention focus: Incident data help reinforce safe-use protocols (time limits, barrier layers, frequent skin assessment) and staff education.

🔸 Documentation nuance: Chart the clinical facts in the medical record; the incident report is separate and not referenced in the chart.

🛏️ Client becomes disoriented and falls out of bed

🟣 Always reportable: Falls are among the most common inpatient adverse events and must be captured for fall-risk surveillance and regulatory reporting.

🟣 Post-fall assessment: Perform a focused head-to-toe, neuro checks, pain assessment, and review anticoagulant status; notify the provider and monitor closely.

🟣 Environmental & systems review: Record lighting, bed height, alarms, footwear, toileting needs, and staffing—key contributing factors for root-cause analysis.

🟣 Care plan updates: Reassess fall-risk score, implement added precautions (low bed, sitters, round frequency), and communicate changes during handoff.

🟣 Separate reporting: Document clinical facts in the chart; complete the incident report for QI, not for blame.

🧑‍🤝‍🧑 Client’s visitor becomes dizzy and faints in the room

🟩 Facility safety event: Injuries/medical events involving visitors on premises also require an incident report for liability and safety monitoring.

🟩 Immediate response: Ensure scene safety, obtain vital signs if feasible, assist to a safe position, call Rapid Response/EMS per policy, and notify leadership.

🟩 Hazard capture: Note environmental factors (spills, clutter, temperature, odors), timing, and witness accounts to identify correctable risks.

🟩 Follow-through: Security/risk management may need to be involved; incident data support visitor education and environmental improvements.

🟩 Documentation practice: Record objective facts; do not mention “incident report filed” in the medical record.

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QLexNursing

2 :
A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?

3 :
A nurse is reinforcing teaching with a newly licensed nurse about HIPAA. Which of the following actions should the nurse include as a violation of HIPAA?

4 :
A nurse is caring for a client who was recently admitted to hospice care and tells the nurse, "I am going to die and my family is hoping for a cure. I am mad that they behave like everything will be fine." Which of the following responses should the nurse make?

5 :
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

6 :
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

7 :
A nurse in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate

8 :
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?

9 :
A nurse is assisting with the care of a client who has a terminal condition, and their family is requesting more guidance and support. Which of the following actions should the nurse take?

10 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

QLexNursing

2 : A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?

3 : A nurse is reinforcing teaching with a newly licensed nurse about HIPAA. Which of the following actions should the nurse include as a violation of HIPAA?

4 : A nurse is caring for a client who was recently admitted to hospice care and tells the nurse, "I am going to die and my family is hoping for a cure. I am mad that they behave like everything will be fine." Which of the following responses should the nurse make?

5 : A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

6 : A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

7 : A nurse in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate

8 : A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?

9 : A nurse is assisting with the care of a client who has a terminal condition, and their family is requesting more guidance and support. Which of the following actions should the nurse take?

10 : A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

2 :
A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?

3 :
A nurse is reinforcing teaching with a newly licensed nurse about HIPAA. Which of the following actions should the nurse include as a violation of HIPAA?

4 :
A nurse is caring for a client who was recently admitted to hospice care and tells the nurse, "I am going to die and my family is hoping for a cure. I am mad that they behave like everything will be fine." Which of the following responses should the nurse make?

5 :
A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?

6 :
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

7 :
A nurse in a long-term care facility is transcribing a prescription for a client. Which of the following abbreviations is appropriate

8 :
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?

9 :
A nurse is assisting with the care of a client who has a terminal condition, and their family is requesting more guidance and support. Which of the following actions should the nurse take?

10 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)