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Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- B. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- C. Report the COVID-19 result to the local health department according to CDC guidelines.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: B
Rationale: Isolating the client from others not wearing proper PPE is the most important action to prevent transmission of COVID-19, given the client's symptoms suggestive of the virus.
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A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?
- A. Weight gain of 2 pounds (0.91 kg) in one day.
- B. Fremitus over the chest wall.
- C. Serum sodium of 150 mEq/L (150 mmol/L).
- D. Urine specific gravity of 1.004.
Correct Answer: A
Rationale: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Sleep with the head of the bed flat.
- B. Take sedatives prior to sleep.
- C. Begin a weight loss program.
- D. Drink 1 to 2 glasses of wine at bedtime.
Correct Answer: C
Rationale: Beginning a weight loss program can reduce OSA by decreasing fat deposits around the neck and chest, which compress the airway, improving breathing during sleep.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Canned vegetables with additional table salt.
- B. Pasta with herbal butter and no meat sauce.
- C. Citrus fruit and melon with a salt substitute.
- D. Whole milk and daily servings of ice cream.
Correct Answer: D
Rationale: Eliminating whole milk and daily ice cream indicates successful teaching, as these high-fat foods can worsen gallbladder inflammation and increase gallstone formation risk.
A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10â¹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
- A. Review need for pneumococcal vaccine.
- B. Implement bleeding precautions.
- C. Assess vital signs every 4 hours.
- D. Place the client in protective isolation.
Correct Answer: D
Rationale: Placing the client in protective isolation is the most important intervention to prevent infections, as a low ANC indicates a high risk of bacterial and fungal infections.
A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?
- A. Restriction of caloric intake.
- B. Fewer fingerstick glucose checks.
- C. Higher doses of insulin.
- D. Increased oral fluid intake.
Correct Answer: C
Rationale: Higher doses of insulin are needed to overcome increased insulin resistance caused by the infection and stress hormones, preventing hyperglycemia and ketoacidosis.