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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

Choice B rationale:

Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.

Choice C rationale:

Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.

Choice D rationale:

Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.

A. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. B. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. C. A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech. D. After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand. E. 1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale:

The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions.

Choice B rationale:

This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention.

Choice C rationale:

This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention.

Choice D rationale:

While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with the facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C.

Choice E rationale:

The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

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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?