Four days after exposure to the coronavirus (COVID-19), a client has a negative COVID-19 test result.
Eight days after the negative test result, the client presents with fever, fatigue, and cough, and the nurse performs a second COVID-19 test.
Which action is most important for the nurse to take?
Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility.
Institute droplet precautions, place the client in a private room, and keep the door closed.
Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Place the nasal swab specimen for COVID-19 directly into a biohazard bag.
Correct Answer : B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Moving Client D into an isolation room 24 hours before surgery is not necessary. The client’s white blood cell (WBC) count is 14,000 mm (14 x 10^9/L), which is higher than the normal range of 5000 to 10,000/mm² (5 to 10 x 10^9/L). This indicates that the client may have an infection. However, it is not standard practice to isolate clients scheduled for surgery based solely on an elevated WBC count. Other factors, such as the presence of specific infectious diseases, would dictate the need for isolation.
Choice B rationale: Asking the dietitian to add a banana to Client C’s breakfast tray is not necessary. The client’s potassium level is 3.8 mEq/L (3.8 mmol/L), which is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore, there is no need to increase the client’s potassium intake.
Choice C rationale: Increasing Client A’s oxygen to 4 liters a minute per cannula is not necessary. The client has emphysema and their oxygen saturation is 94%, which is within the normal range. Increasing the oxygen flow rate could lead to oxygen toxicity or suppress the client’s respiratory drive, leading to respiratory depression or failure.
Choice D rationale: Verifying that Client B has two units of packed cells available is the correct intervention. The client’s postoperative hemoglobin level is 8.2 mg/dL (82 g/L), which is lower than the normal range of 14 to 18 g/dL (140 to 180 g/L). This indicates that the client is anemic and may require a blood transfusion. Therefore, it is important to ensure that packed cells are available if needed.
Correct Answer is D
Explanation
The correct answer is choiced. Notify your healthcare provider if you start having abdominal pain.
Choice A rationale:
Exenatide does not act in the same way as insulin. It is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion, suppresses glucagon secretion, and slows gastric emptying.
Choice B rationale:
Exenatide should be injected within 60 minutes before the morning and evening meals, not within 30 minutes before or after a meal.
Choice C rationale:
There are precautions about taking exenatide with other medications. It can affect the absorption of oral medications, so timing and interactions need to be considered.
Choice D rationale:
Abdominal pain can be a sign of pancreatitis, a serious side effect of exenatide.It is important to notify the healthcare provider if this symptom occurs.
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