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.

Answer and Explanation

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:

Colloidal oatmeal-based lotions can be soothing and moisturizing for dry, itchy skin, but they are not effective in treating the inflammation and scaling associated with psoriasis.

They do not address the underlying hyperproliferation of skin cells that is characteristic of psoriasis.

While they may provide temporary relief of symptoms, they are not a long-term solution for managing the condition.

Choice B rationale:

Topical corticosteroids are the mainstay of treatment for psoriasis.

They work by reducing inflammation, slowing the growth of skin cells, and easing itching and scaling. They come in a variety of strengths and formulations, including creams, ointments, gels, and foams.

The type of corticosteroid and the strength of the medication will depend on the severity of the psoriasis and the location of the lesions.

It's important to follow the healthcare provider's instructions for use carefully, as overuse of topical corticosteroids can lead to side effects such as thinning of the skin and rebound flares.

Choice C rationale:

Topical analgesics, such as lidocaine or benzocaine, can be used to temporarily relieve pain and itching associated with psoriasis.

However, they do not address the underlying inflammation and scaling, and they should not be used as a primary treatment for the condition.

They may be used as adjunctive therapy in conjunction with topical corticosteroids or other psoriasis medications.

Choice D rationale:

Topical antifungal medications are used to treat fungal infections of the skin, such as athlete's foot or ringworm. They are not effective in treating psoriasis, which is an autoimmune condition rather than a fungal infection.

Using a topical antifungal medication for psoriasis could potentially worsen the condition or lead to other skin problems.

A. Leave the old ties in place until the new ones are secure. B. Secure tracheostomy ties by making knots close to the tube. C. Remove ties to secure a disposable, soft foam collar with self-adhesive fastening. D. Place knots of the ties laterally to prevent irritation and pressure.

Correct Answer is A

Explanation

Choice A rationale:

Maintains airway patency: Leaving the old ties in place until the new ones are secure ensures that the tracheostomy tube remains in the correct position and prevents accidental decannulation, which could obstruct the airway and lead to respiratory distress or arrest. This is the most important priority in tracheostomy care.

Prevents tube displacement: Accidental decannulation can occur during tie changes, especially in patients with copious secretions or who are restless or agitated. Keeping the old ties in place acts as a safety measure to keep the tube in position even if the new ties are not immediately secured.

Allows for adjustments: If the new ties are not tied correctly or are too tight, the old ties can be loosened or removed to make adjustments without compromising the airway.

Minimizes anxiety: Leaving the old ties in place can help to reduce anxiety in patients who are apprehensive about the tie- changing process, as it provides a sense of security and ensures that the tube will not be dislodged.

Choice B rationale:

Increases risk of skin irritation: Knots tied close to the tube can rub against the skin, causing irritation, discomfort, and potential skin breakdown, especially in patients with sensitive skin or who have copious secretions.

Impinges on blood flow: Tight knots can also constrict blood vessels, potentially impairing circulation to the skin around the tracheostomy site.

Difficult to remove in emergencies: Knots tied too close to the tube can be challenging to untie quickly in case of an emergency, such as accidental decannulation or the need to suction secretions.

Choice C rationale:

Not appropriate for all patients: Disposable, soft foam collars with self-adhesive fastening may not be suitable for patients with copious secretions, as the adhesive may not adhere well to moist skin.

May not provide adequate support: These collars may not provide the same level of support as traditional tracheostomy ties, especially in patients with active neck movement or who are at risk of accidental decannulation.

Potential for skin irritation: The adhesive on the collar can also irritate the skin around the tracheostomy site in some patients.

Choice D rationale:

May not prevent irritation: Placing knots laterally may not completely eliminate the risk of skin irritation, as the ties can still rub against the skin with neck movement or when the patient is lying down.

Could lead to accidental loosening: Knots tied laterally may be more prone to accidental loosening, especially if the patient is restless or agitated.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed.Which prescription should the nurse teach the client to use for the skin condition?

Correct Answer is B

Explanation

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions.When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Correct Answer is A

Explanation

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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?

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A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

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?