A patient arrives at the emergency department exhibiting symptoms of nausea, vomiting, and diarrhea.
The nurse learns during the physical assessment that the patient’s partner is recovering from COVID-19. After taking a nasal swab to test the patient for COVID-19, what is the most crucial action for the nurse to take?

Advise family members to monitor for symptoms of illness for two weeks after their last contact with the patient.

Implement droplet precautions, place the patient in a private room, and keep the door closed.

Inform the patient to notify others that they may have been potentially exposed in the past 14 days.

Initiate an IV infusion for the administration of an antiviral drug in case of a positive COVID-19 test result.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.

Choice B rationale

Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.

Choice C rationale

Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.

Choice D rationale

Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale

Keeping the head of the bed raised 45 degrees is a common practice in intensive care units to prevent aspiration pneumonia. However, in the context of septic shock, this intervention is not the highest priority.

Choice B rationale

Assessing the warmth of the extremities can provide information about peripheral perfusion. Cold extremities may indicate poor perfusion, a common symptom in septic shock. However, this is not the most critical intervention in the management of septic shock.

Choice C rationale

Maintaining strict intake and output records is crucial in the management of septic shock. Fluid balance is a key component of sepsis management. Monitoring fluid balance helps ensure that the patient is adequately hydrated, which is essential for maintaining blood pressure and organ perfusion.

Choice D rationale

Monitoring the patient’s blood glucose level is important, especially if the patient is receiving insulin or has a history of diabetes. However, in the context of septic shock, this is not the highest priority.

A. “This diagnosis means that I am crazy.”. B. “Many people have the same response to a stressful situation as I am having right now.”. C. “I will probably need to be on medication for the rest of my life.”. D. “I can use holistic approaches like meditation to help my symptoms.”. E. “I am at high risk for post-traumatic stress disorder because I have acute stress disorder.”. F. “I can learn to manage my thoughts better through therapy.”.

Correct Answer is ["A","C"]

Explanation

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.

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Naxlex Comprehensive Predictor Exams

A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider has prescribed a sepsis protocol to be initiated.Which intervention should the nurse prioritize in the plan of care?

Correct Answer is C

Explanation

Which client statements require follow-up teaching by the nurse? Select all that apply.

Correct Answer is ["A","C"]

Explanation

After a scheduled downtime, the computer documentation system fails to restart.What should be the nurse’s initial action?

An elderly patient with osteoarthritis is experiencing increased pain and stiffness in their right knee.What pathological condition should the nurse identify as the cause of these symptoms?

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.