A nurse is caring for a patient with COVID-19 in the intensive care unit. Which nursing action is the MOST important priority when providing care for this patient?
1Don appropriate personal protective equipment (PPE) including N95 respirator, eye protection, gown, and gloves.✓ 정답
2Monitor oxygen saturation levels every 2 hours and document findings in the electronic health record
3Encourage the patient to perform deep breathing exercises and use the incentive spirometer every hour.
4Administer prescribed antiviral medications according to the established medication schedule
해설
Proper PPE use is the highest priority to prevent transmission and protect healthcare workers, as other interventions cannot be safely performed without infection control measures in place.
Core Nursing ExplanationKey Concept Analysis: This question tests the fundamental principle of Infection Control and Safety in a high-risk clinical setting. The core theme is establishing Key Point!nurse and patient safety as the absolute first step before any other assessment or intervention. For a patient with a highly transmissible airborne pathogen like COVID-19 (Coronavirus Disease 2019), the risk of transmission to healthcare workers is significant. The nursing process always begins with a safe environment.
Answer Rationale: Key Point! The correct answer is Donning appropriate PPE. This action aligns with the "Safety First" principle and the Chain of Infection model. To break the chain of transmission (specifically the portal of entry for the nurse), personal protective equipment (PPE) must be used correctly. The Centers for Disease Control and Prevention (CDC) guidelines for airborne precautions for COVID-19 specify the use of an N95 respirator (or higher), eye protection, gown, and gloves. Without this protective barrier, the nurse cannot safely enter the patient's environment to perform any of the other listed interventions without putting themselves at extreme risk. Therefore, it is the indispensable first step.
Distractor Analysis:
Watch out for confusion! Option ② (Monitor oxygen saturation) is a critical assessment for a patient with respiratory illness, but it cannot be performed until the nurse is properly protected. Entering the room without PPE to place a pulse oximeter is a safety violation.
Option ③ (Encourage deep breathing exercises) is an important therapeutic intervention to prevent atelectasis and improve oxygenation, but it requires close patient contact and coaching, which again is unsafe without prior PPE use.
Option ④ (Administer antiviral medications) is a key medical treatment, but medication administration is not the priority over the fundamental safety of the person administering it. The nurse must be protected to prepare and deliver the medication safely.
Related Concepts: This question integrates Transmission-Based Precautions (Airborne Precautions), the nursing process (assessment and implementation phases begin with safety), and priority-setting frameworks like ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. In this context, the nurse's own safety and physiological needs (protection from infection) are a prerequisite for addressing the patient's physiological needs (oxygenation, medication).
Concept Summary
Concept
Description
Application to This Scenario
Airborne Precautions
Used for pathogens spread via small droplet nuclei that remain suspended in air (e.g., COVID-19, Tuberculosis, Measles). Requires N95 respirator, negative pressure room.
Mandates the specific PPE listed in the correct answer before room entry.
Chain of Infection
Infectious agent → Reservoir → Portal of Exit → Mode of Transmission → Portal of Entry → Susceptible Host.
PPE (N95, goggles, gown, gloves) blocks the "Portal of Entry" (nurse's mucous membranes, skin) and protects the "Susceptible Host" (the nurse).
Nursing Process & Safety
Assessment, Diagnosis, Planning, Implementation, Evaluation. Safety is the foundation of all phases.
Implementation of any nursing action (assessment, medication, teaching) requires a safe environment first.
Priority Setting
Using frameworks to determine the order of care. Safety/Threat to Life > Actual Problems > Potential Problems.
An immediate threat to the nurse's safety (exposure without PPE) takes precedence over patient assessments and treatments.
N95 or PAPR (Powered Air-Purifying Respirator), Gown, Gloves, Eye Protection
Negative pressure room, door closed
Droplet Precautions
Influenza, Pertussis, Meningococcal meningitis, COVID-19 (per some earlier guidelines)
Surgical mask, Gown, Gloves, Eye Protection
Private room or cohorting, mask on patient during transport
Contact Precautions
MRSA, VRE, C. difficile, RSV, Draining wounds
Gown, Gloves
Private room or cohorting, dedicated equipment if possible
Anatomy, Physiology & Pharmacology PointsPathophysiology Link: COVID-19 primarily affects the respiratory system, binding to ACE2 receptors in the lungs. This can lead to pneumonia, acute respiratory distress syndrome (ARDS), and hypoxemia, explaining the importance of monitoring oxygen saturation (option 2) and encouraging lung expansion (option 3) after safety is ensured.
Pharmacology Link: Antiviral medications (option 4, e.g., Remdesivir, Paxlovid) work by inhibiting viral replication. Their timely administration is important for clinical outcomes, but the safe administration of any medication is a core nursing responsibility that begins with self-protection.
Memory TipsMnemonic for Airborne PPE: "Never Go In Without Goggles" (N95, Gown, Isolation, [Eye protection] Watch/Goggles). Remember, the order of donning is: Gown → N95 → Goggles → Gloves. Doffing order is typically reverse: Gloves → Goggles → Gown → N95 (perform hand hygiene between steps if contaminated).
Priority Framework: Think "Safety Always Comes First" (SACF). Before addressing the patient's ABCs, ensure your own.
High-Frequency NCLEX Topics
Infection control, especially Transmission-Based Precautions and PPE, is a High Yield area. The NCLEX-RN frequently tests:
1. Selecting the correct type of precaution for a given disease.
2. Identifying the correct sequence for donning and doffing PPE.
3. Determining the priority action when a safety hazard (like infection risk) is present.
4. Patient education on infection prevention.
Watch Out for Question Variations!
* Instead of "most important priority," the question could ask: "Which action should the nurse take first?" The answer remains the same.
* The scenario could change the disease: "A patient with suspected Tuberculosis (TB)" – the priority (donning N95) is identical for airborne precautions.
* The question could test the order of donning PPE or the specific component missing from a described set.
* It could shift to patient education: "The nurse is teaching a family member about home care for a patient with COVID-19. Which instruction is most important?" (Answer would focus on hand hygiene, mask use, and isolation at home).Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Chen, a 68-year-old patient in the ICU with severe COVID-19 pneumonia. He is on high-flow nasal cannula oxygen, appears dyspneic, and has a frequent cough.
Nursing Intervention Strategy:
1. Before Entry (Planning): Review the patient's chart and infection control flag outside the room. Gather all necessary supplies (medications, assessment tools, linen) to minimize entries/exits.
2. Safety Implementation (PPE Donning): Perform hand hygiene. In the anteroom or outside the door, don PPE in the correct sequence: Gown → N95 Respirator (perform seal check) → Eye Protection (goggles or face shield) → Gloves. Ensure all skin and clothing are covered.
3. Patient Care (After Safety is Secured): Enter the room.
* Assessment: Immediately assess Mr. Chen's respiratory status (rate, effort, SpO2), auscultate lung sounds, and check ventilator settings if intubated.
* Intervention: Administer prescribed medications (e.g., antivirals, corticosteroids). Encourage and assist with coughing, deep breathing, and positioning (e.g., prone positioning if ordered) to improve oxygenation.
* Communication: Provide reassurance and explain procedures to reduce anxiety, which can worsen dyspnea.
4. Exiting the Room: Perform hand hygiene with alcohol-based rub while gloves are still on. Doff PPE in the correct sequence to avoid self-contamination: Gloves → Goggles → Gown → N95, performing hand hygiene immediately after removing gloves and again after removing the N95. Dispose of all PPE in the designated biohazard container.
Patient Safety and Precautions:
* Contraindications: Never enter an airborne isolation room without a properly fitted N95 respirator. Do not reuse single-use PPE.
* Monitoring: Be vigilant for signs of your own fatigue or breathing difficulty while wearing an N95 for extended periods. Follow institutional policies for N95 reuse (if allowed) and extended use.
* Equipment: Use dedicated equipment (e.g., stethoscope, blood pressure cuff) in the room whenever possible. If equipment must leave the room, it must be disinfected according to protocol.
Nursing Procedure & Medication FlowPPE Donning/Doffing Sequence:
Step
Action
Key Point
Donning 1
Perform Hand Hygiene
Start with clean hands.
Donning 2
Put on Gown
Tie all ties securely; ensure full coverage from neck to knees.
Donning 3
Put on N95 Respirator
Perform a user seal check (positive and negative pressure check).
Donning 4
Put on Eye Protection
Adjust for a secure fit without gaps.
Donning 5
Put on Gloves
Extend gloves to cover gown cuffs.
Doffing 1
Remove Gloves
Grasp outside of glove with opposite gloved hand; peel off. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at wrist; peel off over first glove. Discard.
Doffing 2
Perform Hand Hygiene
Immediately after glove removal.
Doffing 3
Remove Gown
Unfasten ties. Pull gown away from neck and shoulders, turning it inside out. Fold/roll into a bundle and discard.
Doffing 4
Perform Hand Hygiene
Again after gown removal.
Doffing 5
Remove Eye Protection
Handle by the headband or earpieces. Discard or place in designated receptacle for cleaning.
Doffing 6
Remove N95 Respirator
Grasp bottom ties/elastics, then top ties/elastics. Lift away from face without touching the front. Discard.
Doffing 7
Perform Final Hand Hygiene
Upon complete removal of all PPE.
A Word from Your Senior Nurse
"In the heat of a busy shift, especially in critical care, it's tempting to rush into a room to help a struggling patient. But remember: you are no help to anyone if you become a patient yourself. Taking those extra 60 seconds to don your PPE properly isn't a delay—it's what allows you to be an effective, present, and safe caregiver for your entire shift and for all the shifts to come. On the NCLEX, they are testing this fundamental judgment: can you recognize that your safety is the non-negotiable foundation of all nursing care? Carry that mindset to the bedside, and you'll protect yourself, your colleagues, your patients, and your license."
Airborne Precautions — Infection control measures for diseases transmitted via small droplet nuclei that remain infectious over long distances in the air (e.g., TB, measles, COVID-19). Requires N95 respirator and negative pressure room.
N95 Respirator — A personal protective device that filters at least 95% of airborne particles. It requires a user seal check to ensure proper fit and is essential for airborne precautions.
Chain of Infection — The sequence of events that allows an infection to spread: Infectious Agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host. Breaking any link prevents transmission.
Transmission-Based Precautions — CDC-recommended infection control practices (Contact, Droplet, Airborne) used in addition to Standard Precautions for patients with known or suspected infections.
User Seal Check — A procedure performed by the wearer each time an N95 respirator is donned to ensure an adequate seal to the face. Includes positive pressure check (exhale gently) and negative pressure check (inhale sharply).