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 C

Explanation

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

A. Notify the healthcare provider of the client’s medication history. B. Ensure that the potential for bleeding is explained to the client. C. Have the client sign the surgical and transfusion permits. D. Observe the heparin injection sites for signs of bruising.

Correct Answer is A

Explanation

Notifying the healthcare provider of the client’s medication history is the priority nursing action. Heparin is an anticoagulant, which increases the risk of bleeding. The healthcare provider needs this information to make appropriate decisions about the client’s surgical plan and postoperative care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?

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