Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?
Report the COVID-19 result to the local health department according to the Center for Disease Control (CDC) guidelines.
Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).
Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility.
Place the nasal swab specimen for COVID-19 directly into a biohazard bag.
The Correct Answer is B
Rationale:
A. Report the COVID-19 result to the local health department according to the Center for Disease Control (CDC) guidelines: Reporting is important for public health surveillance but is not the nurse’s most immediate priority. Isolation should occur first to prevent the spread of infection, especially before confirmatory test results are available.
B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE): Prompt isolation is the highest priority to prevent transmission of COVID-19. Even with a previous negative test, current symptoms suggest active infection, and precautions must be implemented immediately to protect others.
C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: While communication with the charge nurse is necessary for client placement, it should follow immediate implementation of infection control measures.
D. Place the nasal swab specimen for COVID-19 directly into a biohazard bag: Proper specimen handling is critical for safety and test integrity but does not take precedence over isolating a potentially infectious client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.3"]
Explanation
Calculation:
- Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 110 lb / 2.2 lb/kg
= 50 kg.
- Calculate the total units of dalteparin the client should receive daily.
Daily units = Desired units/kg × Weight (kg)
= 150 units/kg × 50 kg = 7500 units.
- Determine the volume to administer based on the available prefilled syringe.
The medication is available in a 7,500 units/0.3 mL prefilled syringe.
Since the calculated daily dose (7500 units) exactly matches the units in one prefilled syringe (7500 units), the volume to administer is the volume of that syringe.
Volume to administer:
= 0.3 mL.
Correct Answer is D
Explanation
Rationale:
A. Change to less anxiety-promoting questions: Adjusting questioning techniques may be helpful later, but it does not address the immediate concern of inappropriate behavior. The nurse must first set clear boundaries to maintain safety and therapeutic structure.
B. Ignore the client's inappropriate behavior: Ignoring such behavior may allow it to escalate or reinforce it as acceptable. Clients with mania often test boundaries, so ignoring may compromise safety and therapeutic rapport.
C. Leave the client's room so she can act out her anxiety: Leaving the client alone while she is disinhibited and potentially unsafe is inappropriate. The nurse has a responsibility to redirect behavior and ensure a safe environment.
D. State it is unacceptable to undress during the interview: Clearly and calmly setting limits is the most appropriate first action. It helps maintain dignity, ensures safety, and models acceptable behavior in a therapeutic manner during a manic episode.
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