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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale

A. This action involves assessing the capillary refill of the lower extremity distal to the femoral site. It helps in evaluating peripheral perfusion and circulation to ensure there is no compromise to blood flow. This is important because decreased capillary refill could indicate impaired circulation, possibly due to arterial occlusion or hematoma formation.

B. Checking the femoral insertion site for hematoma formation is crucial after a cardiac catheterization. Hematomas can develop due to bleeding from the femoral artery puncture site, especially if the client is receiving anticoagulant therapy like heparin. A hematoma can compress surrounding structures, potentially causing pain and compromising circulation.

C. While it's important to assess the integrity of IV insertion sites, in this scenario, the primary concern is the groin insertion site used for cardiac catheterization. The IV insertion sites should be assessed regularly for signs of infiltration, phlebitis, or infection, but this should not take precedence over assessing the femoral insertion site for complications related to the procedure.

D. Deep breathing exercises are important for preventing respiratory complications such as atelectasis and pneumonia, especially in clients who are sedated and immobilized. However, in the context of acute pain at the femoral insertion site post-cardiac catheterization, assessing and addressing potential complications related to the procedure take priority.

Correct Answer is ["21"]

Explanation

To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in
minutes.

For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours, with an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / (12 hours * 60 minutes/hour).

This simplifies to (15000 gtt) / (720 minutes), which equals approximately 20.83 gtt/min.

Therefore, the nurse should regulate the infusion to 21 gtt/min, rounding to the nearest whole
number.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["21"]

Explanation

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