The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Move the client to a private room, keep the door closed, and initiate droplet precautions

Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results.

Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Assist the client to recall everyone possibly exposed since onset of symptoms.

Answer and Explanation

The Correct Answer is A

A. Move the client to a private room, keep the door closed, and initiate droplet precautions:
This is the correct answer. Given the client's symptoms and potential exposure to COVID-19, it is important to take infection control measures. Placing the client in a private room, keeping the door closed, and initiating droplet precautions help prevent the potential spread of the virus.

B. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results:
Antiviral medications are typically prescribed based on confirmed COVID-19 test results and the severity of symptoms. Starting an intravenous infusion at this stage, before test results are available, is premature and not indicated.

C. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with the patient:
While it is important for family members to monitor for symptoms, the immediate concern is the isolation and testing of the symptomatic client. Contact tracing may follow, but infection control measures for the client are the priority.

D. Assist the client to recall everyone possibly exposed since onset of symptoms:
While contact tracing is important, the immediate action is to isolate the client and initiate precautions. Contact tracing can be done as part of a broader public health response but is not the initial step.

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Correct Answer is B

Explanation

A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.

B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.

C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.

D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.

A. Encourage regular turning. B. Monitor skin for breakdown C. Assess wound drainage daily. D. Strict IV fluid replacement.

Correct Answer is D

Explanation

A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.

B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.

C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.

D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.

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The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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