A patient presents to the emergency department with nausea, vomiting, and diarrhea.

During the history and physical, it is discovered that the patient’s significant other is recovering from COVID-19. After obtaining a nasal swab to test the patient for COVID-19, what is the most important action for the nurse to take?

Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results.

Move the patient to a private room, keep the door closed, and initiate droplet precautions.

Notify the charge nurse that the patient will need assignment to the COVID-19 specified area of the facility.

Explain to the patient to inform others that they may have been potentially exposed in the last 14 days.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Starting an intravenous infusion for antiviral drug administration is premature at this stage. The patient’s COVID-19 test results are not yet available, and antiviral drugs should not be administered without a confirmed positive test.
Choice B rationale
Moving the patient to a private room, keeping the door closed, and initiating droplet precautions is the most important action. Given the patient’s symptoms and the significant other’s COVID-19 status, these measures will help prevent potential spread of the virus.
Choice C rationale
Notifying the charge nurse for assignment to the COVID-19 specified area of the facility is important, but it is not the immediate priority. The first step should be to initiate droplet precautions to minimize the risk of transmission.
Choice D rationale
While it is important to inform the patient about potential exposure, the immediate priority is to prevent the spread of the virus within the healthcare facility.

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Correct Answer is B

Explanation

Choice A rationale
Rubbing painful areas gently until the pain subsides is not typically recommended for managing pain in Raynaud’s disease. This could potentially cause more harm than good19.
Choice B rationale
Wearing gloves when handling cold items can help guard against painful spasms in Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, so protecting the hands from cold is a key part of managing the condition19.
Choice C rationale
The need for return appointments for IV pain medication is not typically a primary component of pain management in Raynaud’s disease. Pain in Raynaud’s disease is usually managed through lifestyle modifications and medications19.
Choice D rationale
While enrolling in a pain clinic can provide pain relief alternatives, it’s not the first line of management for pain in Raynaud’s disease. The primary management strategies include avoiding cold exposure and using medications to improve blood flow19.

A. Explain the need to limit intake of oral fluids to reduce client discomfort. B. Teach the client techniques for performing intermittent catheterization. C. Remind the client to practice pelvic floor (Kegel) exercises regularly. D. Provide a bedside commode for immediate use in the client’s room.

Correct Answer is B

Explanation

Choice A rationale
Limiting intake of oral fluids is not typically recommended for a client with urinary retention related to sensorimotor deficits in multiple sclerosis. Adequate hydration is important for overall health and can help prevent urinary tract infections14.
Choice B rationale
Teaching the client techniques for performing intermittent catheterization is a common and effective strategy for managing urinary retention in multiple sclerosis. This can help the client maintain independence and improve quality of life14.
Choice C rationale
While pelvic floor (Kegel) exercises can help strengthen the muscles involved in urination, they may not be sufficient to manage urinary retention in a client with multiple sclerosis.
Intermittent catheterization (Choice B) is often more effective14.
Choice D rationale
Providing a bedside commode can be helpful for a client with mobility issues, but it does not directly address the issue of urinary retention in multiple sclerosis14.

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Naxlex Comprehensive Predictor Exams

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

Correct Answer is B

Explanation

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?

Correct Answer is B

Explanation

A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement?

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client’s medical record should the nurse recognize as a contraindication for peritoneal dialysis?