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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?
- A. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results.
- B. Move the patient to a private room, keep the door closed, and initiate droplet precautions.
- C. Notify the charge nurse that the patient will need assignment to the COVID-19 specified area of the facility.
- D. Explain to the patient to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Initiating droplet precautions in a private room prevents potential COVID-19 transmission pending test results.
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The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has a fracture of the femur and is bleeding at the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin subcutaneously daily. Which is the priority nursing action?
- A. Notify the healthcare provider of the client's medication history.
- B. Ensure that the potential for bleeding is explained to the client.
- C. Have the client sign the surgical and transfusion permits.
- D. Observe the heparin injection sites for signs of bruising.
Correct Answer: A
Rationale: Notifying the healthcare provider of the client's heparin use is critical as it increases bleeding risk, requiring potential adjustments to the surgical plan or anticoagulation management.
The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?
- A. White blood cell count.
- B. Platelet count.
- C. Red blood cell count.
- D. Hemoglobin levels.
Correct Answer: B
Rationale: Platelet count is critical as low levels cause petechiae and ecchymosis due to bleeding tendencies.
The healthcare provider prescribes penicillin 200,000 units intramuscularly for a patient with pneumonia. The available vial is labeled 'Penicillin 500,000 units/mL'. How much penicillin should be administered to the patient?
- A. 0.2 mL
- B. 0.4 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: B
Rationale: Dividing the prescribed dose (200,000 units) by the concentration (500,000 units/mL) yields 0.4 mL, the correct volume to administer.
The parent of an adolescent tells the clinic nurse, 'My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' Which instruction should the nurse provide?
- A. Antibiotics take two weeks to become effective against infections such as athlete's foot.
- B. Continue using the ointment for a full week, even after the symptoms disappear.
- C. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.
- D. Stop using the ointment and encourage complete drying of feet and wearing clean socks.
Correct Answer: D
Rationale: Athlete's foot is fungal, not bacterial; stopping antibiotic ointment and keeping feet dry with clean socks aids treatment.
The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
- A. Take prescribed cortisone accurately.
- B. Use a walker when weakness occurs.
- C. Avoid extreme environmental temperatures.
- D. Increase daily intake of sodium in diet.
Correct Answer: A
Rationale: Accurate cortisone administration is vital to manage Addison's disease and prevent adrenal crisis.