Exhibits

A nurse is reviewing the client’s condition. Based on the exhibits provided, what is the most likely diagnosis for this client?

Choice A rationale:

Checking the patient's temperature again is not a priority at this time. The patient's temperature is within the normal range, and there is no indication that it is the cause of the patient's hypoxia.

Focusing on temperature measurement could delay more crucial interventions to address the patient's breathing difficulty.

Choice B rationale:

While monitoring the patient's heart rate is important, it is not the most immediate priority in this situation. The patient's heart rate is elevated, but it is not dangerously high.

The elevated heart rate is likely a compensatory response to the patient's low oxygen saturation. Addressing the underlying cause of the hypoxia, which is likely respiratory in nature, will also help to stabilize the heart rate.

Choice C rationale:

Observing the patient's breathing is the most important action the nurse can take at this time. The patient's respirations are rapid and shallow, indicating respiratory distress.

This is a serious condition that requires immediate intervention. By observing the patient's breathing, the nurse can assess the severity of the distress and determine the best course of action.

The nurse can observe for signs of increased work of breathing, such as use of accessory muscles, nasal flaring, and retractions. They can also auscultate the lungs to assess for any abnormal breath sounds, such as wheezing or crackles.

This information will help the nurse to determine the underlying cause of the respiratory distress and to initiate appropriate interventions, such as administering oxygen, positioning the patient, or calling for assistance from a respiratory therapist.

Choice D rationale:

Checking the patient's blood pressure is not a priority at this time. The patient's blood pressure is within the normal range. While it is important to monitor the patient's blood pressure, it is not the most immediate concern in this situation.

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.

Focusing on isolation at this point is a more effective way to prevent further transmission.

Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.

Choice B rationale:

Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:

COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.

Isolation physically separates the infected person from others, reducing the risk of transmission.

Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.

Choice D rationale:

Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.