A patient presents to the emergency department with nausea, vomiting, and diarrhea.

During the history and physical, it is discovered that the patient’s significant other is recovering from COVID-19. After obtaining a nasal swab to test the patient for COVID-19, what is the most important action for the nurse to take?

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

Move the patient to a private room, keep the door closed, and initiate droplet precautions.

Notify the charge nurse that the patient will need assignment to the COVID-19 specified area of the facility.

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

Answer and Explanation

The Correct Answer is B

Choice A rationale
Starting an intravenous infusion for antiviral drug administration is premature at this stage. The patient’s COVID-19 test results are not yet available, and antiviral drugs should not be administered without a confirmed positive test.
Choice B rationale
Moving the patient to a private room, keeping the door closed, and initiating droplet precautions is the most important action. Given the patient’s symptoms and the significant other’s COVID-19 status, these measures will help prevent potential spread of the virus.
Choice C rationale
Notifying the charge nurse for assignment to the COVID-19 specified area of the facility is important, but it is not the immediate priority. The first step should be to initiate droplet precautions to minimize the risk of transmission.
Choice D rationale
While it is important to inform the patient about potential exposure, the immediate priority is to prevent the spread of the virus within the healthcare facility.

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale
While monitoring skin for breakdown is an important aspect of nursing care, especially for bedridden or immobile patients, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice B rationale
An anastomotic leak is a serious complication that occurs when the surgical connection between two parts of the intestine leaks, allowing the contents of the gastrointestinal tract to leak into the abdominal cavity. This can lead to serious infection and sepsis. Strict intravenous
(IV) fluid replacement is crucial in this situation to prevent dehydration and maintain blood pressure.
Choice C rationale
Encouraging regular turning is an important aspect of nursing care to prevent pressure ulcers, especially for bedridden or immobile patients. However, it is not the most important intervention for a client admitted with possible anastomosis leakage.
Choice D rationale
Assessing wound drainage daily is an important aspect of postoperative care. However, in the case of a suspected anastomotic leak, more immediate and critical interventions are required.

A. Lumbar puncture B. Skull radiography C. Magnetic resonance imaging (MRI) D. Computerized tomography (CT) scan

Correct Answer is A

Explanation

Choice A rationale
As with, a lumbar puncture is the primary diagnostic procedure for suspected bacterial meningitis. The other choices, while useful for detecting other conditions, are not as definitive for diagnosing bacterial meningitis.
Choice B rationale
As mentioned in the rationale for, Choice B, skull radiography is not typically used to diagnose bacterial meningitis.
Choice C rationale
As mentioned in the rationale for, Choice C, an MRI can provide detailed images of the brain and surrounding tissues, but it is not the primary tool for diagnosing bacterial meningitis.
Choice D rationale
As mentioned in the rationale for, Choice D, a CT scan can detect abnormalities in the brain, but it cannot definitively diagnose bacterial meningitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?

Correct Answer is A

Explanation

What information should the nurse include in the teaching plan for a patient diagnosed with gastroesophageal reflux disease (GERD)?

Following a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

A patient with a full-thickness burn covering 40% of their body is exhibiting purulent drainage at the wound site. Before reporting this finding to the healthcare provider, which of the patient’s laboratory values should the nurse review?

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?