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.

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Correct Answer is A

Explanation

Choice A rationale
Encouraging the client to continue their walking routine is a supportive and positive response. This acknowledges the client’s desire to stay active and engage in activities they enjoy despite their osteoarthritis. It promotes a sense of empowerment and independence, which can be important for overall well-being.
Choice B rationale
Advising less weight-bearing to prevent joint destruction may seem logical, but it is not the best advice. Regular exercise, including walking, can actually help manage osteoarthritis by strengthening the muscles around the joints, improving flexibility, and reducing pain.
Choice C rationale
Recommending walking indoors for improved stability and safety might be helpful in some cases, but it is not necessarily the best response. The client has expressed a desire to continue walking in the park with friends, which also has social and mental health benefits.
Choice D rationale
Suggesting a calcium supplement along with continued walking is not the best advice. While calcium is important for bone health, osteoarthritis is not caused by a lack of calcium. It’s a degenerative joint disease that involves the breakdown of cartilage in the joints.

A. Use an incentive spirometer. B. Monitor the urinary stream for decreased output. C. Restrict physical activities. D. Report when hematuria becomes pink-tinged.

Correct Answer is B

Explanation

Choice A rationale
Using an incentive spirometer is generally recommended for respiratory conditions to improve lung function, not specifically for a client with hydronephrosis and a history of renal calculi.
Choice B rationale
Monitoring the urinary stream for decreased output is crucial for a client with hydronephrosis and a history of renal calculi. Hydronephrosis is a condition characterized by urine accumulation in the kidney, which can lead to decreased urine output. Therefore, monitoring urinary output can help detect any potential complications or worsening of the condition.
Choice C rationale
Restricting physical activities is not typically necessary for a client with hydronephrosis and a history of renal calculi unless specified by the healthcare provider. It’s more important to focus on maintaining overall health and well-being.
Choice D rationale
Reporting when hematuria becomes pink-tinged is not the most relevant instruction for a client with hydronephrosis and a history of renal calculi. While it’s important to report any changes in urine color, monitoring urinary output (Choice B) is more directly related to the client’s condition.

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Naxlex Comprehensive Predictor Exams

A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

Correct Answer is A

Explanation

A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client’s discharge instructions?

Correct Answer is B

Explanation

The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?

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?

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

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?