A client presents to the emergency department with nausea, vomiting, and diarrhea. While obtaining the history and physical assessment, the nurse discovers that the client's significant other is recovering from COVID 19. After obtaining a nasal swab to test the client for COVID 19, which action is most important for the nurse to take?
Start an IV infusion for antiviral drug to be administered for positive COVID 19 test results.
Institute droplet precautions, place client in a private room, and keep the door closed.
Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.
Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
The Correct Answer is B
Rationale
A. Starting IV infusion for antiviral drugs is premature without confirmation of COVID-19 diagnosis. Antiviral treatment for COVID-19 is typically initiated based on positive test results and clinical assessment by the healthcare provider. It is important to wait for test results before starting specific treatment protocols.
B. Given the client's symptoms and exposure history to someone with COVID-19, it is crucial to implement droplet precautions. This includes placing the client in a private room with the door closed to minimize the risk of airborne transmission. Healthcare providers should wear appropriate personal protective equipment (PPE), including masks (N95 respirator or surgical mask), gown, gloves, and eye protection, when entering the room.
C. This action is appropriate to inform family members about potential exposure to COVID-19. Symptoms can develop up to 14 days after exposure, so monitoring for symptoms is essential. However, immediate isolation and precautions for the client are more critical at this stage.
D. While it is important for the client to inform others about potential exposure, the immediate concern is implementing isolation precautions for the client and preventing further transmission within the healthcare setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. JVD is typically an indicator of increased central venous pressure and can be associated with heart failure or fluid overload. In this scenario, flat JVD suggests decreased venous return, which may exacerbate the client's hypotension. While important, it may not be the most immediate concern compared to other options.
B. Changes in consciousness, such as confusion, disorientation, or loss of consciousness, are critical signs that indicate poor cerebral perfusion. In this case, the rapid ventricular rate and possibly inadequate cardiac output may not be meeting cerebral perfusion needs, leading to altered mental status. This finding requires urgent attention to prevent further deterioration.
C. Nausea and vomiting can indicate inadequate perfusion to the gastrointestinal tract due to hypotension or impaired cardiac output. While important to assess for fluid and electrolyte balance, it is less urgent compared to potential changes in mental status or perfusion to vital organs.
D. A sudden onset headache can be indicative of various issues, including hypertension, cerebral ischemia, or intracranial hemorrhage. However, in the context of atrial fibrillation with rapid ventricular response and hypotension, other neurological signs such as altered mental status or focal neurological deficits would typically be more concerning.
Correct Answer is C
Explanation
Rationale
A. Both baked potato with skin and raw carrots are high-fiber foods. The skin of the potato and raw carrots contain significant amounts of fiber, which can aggravate symptoms of ulcerative colitis.
B. Whole-grain cereals are high in fiber, which is not suitable for a low-fiber diet recommended for ulcerative colitis.
C. Roasted turkey is a lean protein source and generally suitable for a low-fiber diet. Canned vegetables can vary in fiber content; however, they are typically lower in fiber compared to fresh vegetables. The nurse should verify the specific type of canned vegetables to ensure they are low in fiber.
D. Fresh strawberries are high in fiber and should be avoided on a low-fiber diet.
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