NCLEX Practice Test

A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question?

1. Dons a mask with eye shield before irrigating a draining wound for a client on standard precautions

2. Places a "soap and water only" sign on the door of a client with Clostridium difficile

3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV

4. Wears an N95 respirator before entering the room of a client with active varicella-zoster

The correct answer is: Dons a mask with eye shield before irrigating a draining wound for a client on standard precautions

The charge nurse's actions are important in maintaining infection control and ensuring safety for both healthcare providers and patients. The measure of donning a mask with an eye shield before irrigating a draining wound for a client on standard precautions raises questions because standard precautions do not typically require this level of personal protective equipment (PPE) unless there is a specific risk of splash or spray. In wound care, unless there's a significant risk of exposure to bodily fluids, wearing a mask and eye protection may not be routinely necessary under standard precautions. Standard precautions mainly call for gloves when coming into contact with blood or other potentially infectious materials, and additional PPE should only be utilized based on the nature of the procedure and the level of risk involved. Conversely, placing a "soap and water only" sign on the door of a client with Clostridium difficile is a key action to prevent the spread of infection, as C. difficile is spores that need thorough hand hygiene. Wearing two pairs of gloves while handling the urinary catheter collection bag of a client with HIV is also a valid measure since HIV is transmitted through blood and certain body fluids, warranting additional precautions. Lastly, an N95 respirator is appropriate when dealing with a client with active varicella-zoster, as