An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life.

The client is accompanied by a close friend, but no family members are available.

Which action should the nurse take first?

The correct answer is Choice B.

Choice A rationale: While notifying the charge nurse about the client’s condition is important, it is not the most critical action. The charge nurse’s role would be to coordinate care and ensure appropriate resources are available, but the immediate safety and well-being of the client and others in the facility is the priority. Therefore, this choice is not the most important action for the nurse to take.

Choice B rationale: Instituting droplet precautions, placing the client in a private room, and keeping the door closed is the most important action. COVID-19 is primarily spread through respiratory droplets when an infected person coughs, sneezes, or talks. It can also be spread by touching a surface or object that has the virus on it and then touching the mouth, nose, or eyes. Therefore, it is crucial to implement droplet precautions to prevent the spread of the virus. This includes wearing a mask, eye protection, and a gown and gloves when caring for the client. The client should also be placed in a private room with the door closed to further prevent the spread of the virus.

Choice C rationale: While it is important for the client to inform others that they may have been potentially exposed, this is not the most critical action. The priority is to prevent the spread of the virus within the healthcare facility. Once the client is appropriately isolated and precautions are in place, the client can be educated and assisted with notifying others about potential exposure.

Choice D rationale: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is a standard procedure when collecting specimens for testing. However, this action does not address the immediate need to prevent the spread of the virus within the healthcare facility. Therefore, this choice is not the most important action for the nurse to take.

Choice A rationale:

Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.

Choice B rationale:

Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.

Choice C rationale:

Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.

Choice D rationale:

Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.