A client presents to the emergency department with nausea, vomiting, and diarrhea. While obtaining the history and physical assessment, the nurse discovers that the client's significant other is recovering from COVID 19. After obtaining a nasal swab to test the client for COVID 19, which action is most important for the nurse to take?

Start an IV infusion for antiviral drug to be administered for positive COVID 19 test results.

Institute droplet precautions, place client in a private room, and keep the door closed.

Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Explain to the client to inform others that they may have been potentially exposed in the last 14 days.

Answer and Explanation

The Correct Answer is B

Rationale

A. Starting IV infusion for antiviral drugs is premature without confirmation of COVID-19 diagnosis. Antiviral treatment for COVID-19 is typically initiated based on positive test results and clinical assessment by the healthcare provider. It is important to wait for test results before starting specific treatment protocols.

B. Given the client's symptoms and exposure history to someone with COVID-19, it is crucial to implement droplet precautions. This includes placing the client in a private room with the door closed to minimize the risk of airborne transmission. Healthcare providers should wear appropriate personal protective equipment (PPE), including masks (N95 respirator or surgical mask), gown, gloves, and eye protection, when entering the room.

C. This action is appropriate to inform family members about potential exposure to COVID-19. Symptoms can develop up to 14 days after exposure, so monitoring for symptoms is essential. However, immediate isolation and precautions for the client are more critical at this stage.

D. While it is important for the client to inform others about potential exposure, the immediate concern is implementing isolation precautions for the client and preventing further transmission within the healthcare setting.

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Correct Answer is B

Explanation

Rationale

A. This role oversees the neurology unit but may not be directly involved in ICU care coordination, which requires a focus on acute management and transition to rehabilitation.

B. Nurse case managers are skilled in coordinating care for patients with complex conditions, ensuring continuity of care, and facilitating communication among healthcare providers and the client's family.

C. While an NP may be involved in direct patient care, their role is more focused on clinical management rather than comprehensive care coordination across different disciplines.

D. This role deals with patient safety and risk reduction but is not primarily responsible for coordinating care for a specific patient's acute medical needs and rehabilitation planning.

A. Drink electrolyte fluid replacements. B. Resume normal physical activity. C. Give a dose of regular insulin as prescribed. D. Measure urine output over the next 24 hours.

Correct Answer is C

Explanation

Rationale

A. This option may seem reasonable, as dehydration and electrolyte imbalances are concerns in DKA. However, simply drinking electrolyte fluids without addressing the underlying cause of DKA (which is insulin deficiency) would not effectively manage the condition.

B. Physical activity may exacerbate DKA if insulin levels are inadequate. It is important to stabilize blood glucose levels and manage DKA before engaging in physical activity.

C. In DKA, there is an absolute or relative deficiency of insulin, leading to hyperglycemia and ketosis. Regular insulin helps to lower blood glucose levels and inhibit further breakdown of fats into ketones, thereby correcting the metabolic imbalance associated with DKA.

D. Monitoring urine output is important in assessing hydration status, but it does not address the immediate need to manage DKA. This action alone would not correct the underlying cause of increased thirst in DKA.

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Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is B

Explanation

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is C

Explanation

The nurse is preparing for discharge a client with a history of celiac disease who now has developed multiple sclerosis. Which instruction is most important for the nurse to include in the discharge teaching plan?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

Exhibits Based on the assessment data, the nurse recognizes the need to intervene immediately. Select the 5 priority interventions that the nurse should initiate based on the most recent assessment.

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?