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 A

Explanation

Rationale

A. This action helps maintain adequate cerebral perfusion pressure and venous drainage, which is important in suspected stroke cases. It supports optimal cerebral blood flow and reduces the risk of increased intracranial pressure. However, it's not the immediate intervention required for this client. The primary focus initially is on diagnostic evaluation and stabilization.

B. Elevating the joints on the affected side can help reduce dependent edema and promote circulation. This intervention is part of ongoing nursing care to prevent complications like deep vein thrombosis (DVT) in stroke patients who may have reduced mobility. While important, it is not the immediate priority in the acute phase of management.

C. Gathering a focused history is crucial to understanding potential causes or exacerbating factors contributing to the client's symptoms While important, it is not the immediate priority in the acute phase of management.

D. Intermittent pneumatic compression devices (IPC) are used to prevent deep vein thrombosis (DVT) by enhancing venous return and preventing stasis in the lower extremities. While DVT prevention is important in stroke patients, it is not the immediate intervention required for the client's acute neurological symptoms.

A. Alert the nursing staff of the client's do not resuscitate status. B. Facilitate a family meeting with the palliative care team. C. Notify the healthcare provider of the client's wishes. D. Place a certified copy of the living will in the client's record.

Correct Answer is C

Explanation

Rationale

A. A living will often includes directives regarding life-sustaining treatments, including intubation. If the living will explicitly states a preference against intubation, the nurse should ensure this information is known to the healthcare team. However, a living will does not automatically imply a DNR status unless specifically stated.

B. When a living will is presented, and decisions need to be made regarding life-sustaining treatments like intubation, it is appropriate to facilitate a family meeting. In this meeting, the healthcare team, including palliative care specialists if available, can discuss the client's wishes as outlined in the living will. The goal is to ensure everyone understands the client's preferences and to make informed decisions about the course of treatment.

C. The nurse should notify the attending healthcare provider about the existence of the client's living will and its directives regarding medical interventions such as intubation. The healthcare provider needs to be aware of the client's wishes to guide the decision-making process and ensure appropriate care is provided according to the client's preferences.

D. It is crucial to ensure that the living will, once verified and certified as authentic, is placed in the client's medical record. This document serves as a legal and ethical guide for healthcare decisions, especially during critical situations like an exacerbation requiring intubation.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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