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 D

Explanation

A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.

B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.

C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.

D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.

A. Guidelines for oxygen use. B. Methods for weight loss. C. Approaches to conserve energy. D. Strategies for smoking cessation.

Correct Answer is D

Explanation

A. Guidelines for oxygen use:
While guidelines for oxygen use are important, addressing the root cause of the respiratory condition, which includes smoking cessation, is crucial for long-term management.

B. Methods for weight loss:
Obesity can contribute to respiratory issues, but in the immediate context of emphysema exacerbation and the need for oxygen therapy, smoking cessation is a more urgent concern.

C. Approaches to conserve energy:
Conserving energy is important for clients with emphysema, but addressing the impact of smoking on respiratory function is a more immediate priority.

D. Strategies for smoking cessation.
Smoking is a major contributor to the progression of emphysema and exacerbation of respiratory symptoms. Addressing smoking cessation is crucial in improving the client's respiratory function and overall health. Continuing to smoke can exacerbate emphysema and compromise the effectiveness of other interventions, including oxygen therapy.

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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

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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