An adult male was diagnosed with stage IV lung cancer three weeks ago.

His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies.

Which is the best response by the nurse?

Choice A rationale:

Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.

Choice B rationale:

Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.

Choice C rationale:

Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.

Choice D rationale:

Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.

The correct answer is Choice B.

Choice A rationale: While notifying the charge nurse about the client’s condition is important, it is not the most critical action. The charge nurse’s role would be to coordinate care and ensure appropriate resources are available, but the immediate safety and well-being of the client and others in the facility is the priority. Therefore, this choice is not the most important action for the nurse to take.

Choice B rationale: Instituting droplet precautions, placing the client in a private room, and keeping the door closed is the most important action. COVID-19 is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. It can also be spread by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes. Therefore, it is crucial to implement droplet precautions to prevent the spread of the virus. This includes wearing a mask, eye protection, and a gown and gloves when caring for the client. The client should also be placed in a private room with the door closed to further prevent the spread of the virus.

Choice C rationale: While it is important for the client to inform others that they may have been potentially exposed, this is not the most critical action. The priority is to prevent the spread of the virus within the healthcare facility. Once the client is appropriately isolated and precautions are in place, the client can be educated and assisted with notifying others about potential exposure.

Choice D rationale: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a standard procedure when collecting specimens for testing. However, this action does not address the immediate need to prevent the spread of the virus within the healthcare facility. Therefore, this choice is not the most important action for the nurse to take.