A patient arrives at the emergency department exhibiting symptoms of nausea, vomiting, and diarrhea.
The nurse learns during the physical assessment that the patient’s partner is recovering from COVID-19. After taking a nasal swab to test the patient for COVID-19, what is the most crucial action for the nurse to take?

Advise family members to monitor for symptoms of illness for two weeks after their last contact with the patient.

Implement droplet precautions, place the patient in a private room, and keep the door closed.

Inform the patient to notify others that they may have been potentially exposed in the past 14 days.

Initiate an IV infusion for the administration of an antiviral drug in case of a positive COVID-19 test result.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.

Choice B rationale

Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.

Choice C rationale

Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.

Choice D rationale

Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale

Methylergonovine is used after childbirth to help control bleeding and improve muscle tone in the uterus. Administering 0.2 mg of methylergonovine IM can help to control postpartum hemorrhage in this patient.

Choice B rationale

Notifying the primary healthcare provider is crucial in this situation. The healthcare provider needs to be aware of the patient’s condition and the interventions being initiated.

Choice C rationale

Inserting a straight catheter can help to manage urinary retention, which could be a potential issue given the patient’s prolonged labor and use of epidural anesthesia.

Choice D rationale

Massaging the fundus until it is firm can help to stimulate uterine contractions, which can control bleeding and prevent postpartum hemorrhage.

Choice E rationale

Counting saturated pads per hour can help to monitor the amount of bleeding and assess the effectiveness of the interventions.

A. Listen for bilateral breath sounds. B. Verify a capillary refill time of less than 3 seconds. C. Check that the ETT markings are between 22 and 26 cm at the teeth line. D. Observe for symmetrical chest movement. E. Arrange for a portable chest x-ray to confirm ETT location.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale

Listening for bilateral breath sounds is a common method to confirm the correct placement of the ETT1. When the ETT is correctly placed, breath sounds should be heard equally on both sides of the chest.

Choice B rationale

Verifying a capillary refill time of less than 3 seconds is not directly related to confirming the placement of an ETT. Capillary refill time is often used to assess peripheral circulation and hydration status, not airway management.

Choice C rationale

Checking that the ETT markings are between 22 and 26 cm at the teeth line is another method to confirm correct ETT placement. These markings help ensure that the ETT is not too far into the trachea, which could cause one lung to be ventilated more than the other.

Choice D rationale

Observing for symmetrical chest movement is a visual confirmation of correct ETT placement. When the ETT is correctly placed, both sides of the chest should rise and fall equally with each breath.

Choice E rationale

Arranging for a portable chest x-ray is considered the gold standard for confirming ETT location. It provides a visual confirmation that the ETT is in the trachea and not in the esophagus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

A young adult is admitted to the emergency department after consuming an unknown quantity of drugs.The patient is unresponsive, and an endotracheal tube (ETT) has been inserted.What methods should the nurse use to confirm the correct placement of the ETT? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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