A nurse is caring for a patient with suspected tuberculosis in the emergency department. Which personal protective equipment (PPE) sequence demonstrates the correct donning procedure for airborne precautions?

The correct donning sequence starts with hand hygiene, followed by gown, mask, eye protection, gloves, and final hand hygiene check, ensuring minimal contamination risk for tuberculosis. Other sequences may compromise protection.

Correct Answer Sequence for Airborne Precautions PPE Donning

The correct sequence for donning personal protective equipment when caring for a patient with suspected tuberculosis under airborne precautions is hand hygiene, then gown, then mask, then eye protection, then gloves, then final hand hygiene check. This sequence is not arbitrary; it is a systematic process designed to create a complete barrier between the healthcare provider and the infectious pathogen while minimizing the risk of self-contamination during the donning process itself.

Step-by-Step Rationale

The procedure begins with hand hygiene. This foundational step decontaminates the hands, ensuring that any pathogens already on the provider's skin are not trapped against the body under a new gown or transferred to the clean PPE items during application . The hands are the primary vector for contact transmission, and starting with a clean field is a non-negotiable principle of infection prevention .

The second step is donning the gown. The gown is applied first among the physical barriers because it covers the largest surface area of the body and trunk. Applying it early prevents contamination of the provider’s clothing and skin. It is secured at the neck and waist to create a stable foundation for the subsequent equipment. Applying the gown before the mask and eye protection is logical, as the ties and adjustments for the gown are performed below the head and neck, reducing the risk of accidentally dislodging a mask that has already been fitted.

The third step is donning the mask or particulate respirator (e.g., N95). For airborne precautions, this is the most critical piece of equipment because tuberculosis is transmitted via droplet nuclei that remain suspended in the air . The respirator must be applied after the gown to allow for an unimpeded fit check. The provider uses both hands to mold the nosepiece and secure the straps, a process that requires a full range of motion without interference from a face shield or goggles. A proper seal is essential, and performing a user seal check immediately after donning confirms the respirator’s integrity .

Following the mask, eye protection (goggles or a face shield) is applied. This equipment protects the mucous membranes of the eyes from infectious droplets that may be generated during a patient’s cough or an aerosol-generating procedure. It is placed after the mask to ensure the top of the mask and the eye protection can be properly adjusted to sit flush against the face without gaps, and so the mask straps do not interfere with the fit of the goggles.

Gloves are the final piece of PPE to be donned. This step is deliberately last because the gloves must create a continuous barrier over the cuff of the gown. By pulling the glove cuffs up and over the wrist of the gown, the provider eliminates any exposed skin between the sleeve and the hand. If gloves were applied earlier, the process of donning the mask, securing the gown, or adjusting eye protection could tear or contaminate them, breaking the protective barrier .

The sequence concludes with a final hand hygiene check after all items are in place. This is a cognitive and visual confirmation that the barriers are intact and properly positioned. While the hands are now gloved, this step reinforces the principle of hand hygiene as a continuous practice and serves as a final safety pause before entering the patient’s environment. This contrasts with option 1, which omits this critical final verification, and option 2, which illogically places hand hygiene at the very end after all contact with potentially contaminated PPE surfaces has already occurred. Option 4 is incorrect because performing hand hygiene in the middle of the sequence after handling a mask and eye protection introduces a risk of contaminating the clean hands when subsequently donning the gown. The correct sequence ensures that each piece of equipment is applied from the cleanest to the least clean, moving from the core of the body outward, a principle that underpins all PPE donning protocols [1,3].