A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.
The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?
Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).
Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines.
Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.
The Correct Answer is B
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.
It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.
Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.
Choice B rationale:
Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.
PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.
Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.
It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.
The priority is to prevent further transmission by isolating the client.
Choice D rationale:
Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.
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Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.
Focusing on isolation at this point is a more effective way to prevent further transmission.
Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.
Choice B rationale:
Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:
COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.
Isolation physically separates the infected person from others, reducing the risk of transmission.
Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.
Choice D rationale:
Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.
Correct Answer is A
Explanation
Rationale for Choice A:
Pursed-lip breathing:
Creates back pressure in the airways, which helps to keep them open longer during exhalation.
Slows down the breathing rate, allowing for more complete exhalation and better emptying of the lungs. Prevents air trapping, which can worsen shortness of breath.
Promotes relaxation and reduces anxiety, which can also help to improve breathing.
Rationale for Choice B:
Side-lying position with knees bent:
May not be the most effective position for improving gas exchange in a client with emphysema. Could potentially restrict chest expansion and make breathing more difficult.
May not be comfortable for all clients.
Rationale for Choice C:
Increasing breathing rate:
Can lead to hyperventilation, which can worsen shortness of breath and anxiety. Can also cause fatigue and muscle exhaustion.
Rationale for Choice D:
Raising hands above the head:
Does not significantly expand the diaphragm or improve gas exchange. May actually make breathing more difficult for some clients.
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