BSN 266 HESI (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100 Correct Grade A

BSN 266 HESI (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100 Correct Grade A BSN 266 HESI Study online at 1. A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? a. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope. b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. c. Verify troponin level assessments are scheduled every 3-6 hours for a series of three. d. Obtain a 12- lead electrocardiogram and begin continuous cardiac monitoring. D 2. A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication? a. anxiety and sighing b. myalgia in wrists and hands c. hyperactive bowel sounds d. dark yellow urine B 3. 4While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the clients hand grips. The client reports joint pain and trouble twisting a door knob due to weaknesses. Which action should the nurses take in response to these figures? a. Implement fall precautions to reduce the clients risk of injury. C Explanation: The nurse should gather additional assessment data about the pain and weakness to better understand the client's condition and to determine if there is an underlying issue or if the 1 / 23 BSN 266 HESI Study online at b. Explain that relief of the migraine pain will reduce related symptoms. c. Gather additional assessment data about the pain and weakness. d. Consult with the occupational therapist for a functional assessment symptoms are related to the migraine headaches. 4. 5. A client who has developed acute kidney injury (AKI) due to aminoglycoside antibiotics has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor? a. Uremic irritation of mucous membranes and skin surfaces. b. Hypovolemia and electrocardiographic (ECG) changes. c. Side effects of total parental nutrition (TPN) and Intralipids. d. Elevated creatinine and blood urea nitrogen (BUN). B Explanation: During the diuretic phase of AKI, the client may experience increased urine output, which can lead to hypovolemia and electrolyte imbalances. Monitoring for hypovolemia and ECG changes can help detect any complications or worsening of the client's condition. 5. 6. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? a. Thick skin plaques topped by silvery white scales b. Tenderness upon palpation and generalized erythema c. Brown, rough, greasy, wart-like papules on the face d. Requires sunglasses because sunlight hurts eyes B Explanation: Overexposure to PUVA treatment can cause skin irritation, tenderness, and erythema. If the client exhibits these symptoms, the nurse should notify the healthcare provider for possible treatment modifications. 6. 2 / 23 BSN 266 HESI Study online at 7. An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101* F (38 3* C). heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg. Which intervention is most important for the nurse to include in the client's plan of care? a. Encourage regular turning. b. Monitor skin for breakdown. c. Strict IV fluid replacement. d. Assess wound drainage daily. C Explanation: The client's vital signs indicate possible sepsis or systemic infection. Strict IV fluid replacement is important to maintain adequate circulation, support blood pressure, and treat potential sepsis. The other interventions are also essential but not as critical as fluid replacement in this situation. 7. 8. A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instructions should the nurse provide? a. Painful areas should be rubbed gently until the pain subsides. b. Return appointments will be needed for IV pain medications. c. Enrolling in a pain clinic can provide relief alternatives. d. Wearing gloves when handling cold items guards against painful spasms. D Explanation: For clients with Raynaud's disease, cold temperatures can trigger painful episodes. Instructing the client to wear gloves when handling cold items can help protect against these episodes and manage pain. 8. 9. A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? a. Explain that the need to restrict fluids is the primary limitation. b. Advise the client to limit foods that are high in calcium and iron. c. Instruct the client to avoid foods with gluten, such as wheat bread. d Explanation: Individuals with Crohn's disease often have specific trigger foods that exacerbate their symptoms. The nurse should describe the use of an elimination diet to 3 / 23 BSN 266 HESI Study online at d. Describe the use of an elimination diet to find trigger foods. help the client identify and avoid these trigger foods to better manage their condition. 9. 10. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi.? a. Jogs more frequently than usual daily routine. b. Eats a vegetarian diet with cheese 2 to 3 times a day. c. Experiences additional stress since adopting a child. d. Drinks several bottles of carbonated water daily. B Explanation: Diets high in animal protein, such as cheese, can increase the risk of kidney stones. While the other options do not pose a direct risk for renal calculi, a diet high in animal protein can contribute to the formation of stones. 10. 11. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary system, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. Review the client's fluid intake prior to bedtime. b. Obtain a fingerstick blood glucose level. c. Palpate the bladder above the symphysis pubis. d. Collect a urine specimen for culture analysis. C Explanation: The client's symptoms suggest possible urinary retention, which is common in older males with benign prostatic hyperplasia (BPH). Palpating the bladder above the symphysis pubis can help the nurse assess for bladder distention and provide information to guide further evaluation and management. 11. 12. The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which C Explanation: Carcinogens are substances that can cause changes in a 4 / 23 BSN 266 HESI Study online at statement indicates an accurate understanding? a. Environmental factors such as sunlight and chemicals can cause cancer to spread. b. Carcinogens are substances that contain cancerous cells. c. Substances that change a cell so that it becomes cancerous are potential sources of cancer. d. Carcinogens are in the environment and cannot be avoided. cell's DNA, leading to the development of cancer. Understanding that carcinogens are potential sources of cancer indicates accurate knowledge of this concept. 12. 13. A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next? a. Capillary glucose. b. Oxygen saturation. c. Body temperature. d. Blood pressure. D Explanation: Clients with pheochromocytoma can experience paroxysmal episodes of hypertension due to the release of catecholamines from the tumor. The onset of a severe headache and diaphoresis in a client with pheochromocytoma may indicate a hypertensive crisis, so the nurse should obtain the client's blood pressure next. 13. 14. A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? a. Nephrotic syndrome history. b. Latent hepatitis C. C Explanation: Crohn's disease with a history of colectomy is a contraindication for peritoneal dialysis due to the increased risk of peritonitis and complications 5 / 23 BSN 266 HESI Study online at c. Crohn's disease with colectomy. d. Type 2 diabetes mellitus. related to abdominal surgery. The other conditions listed do not directly contraindicate peritoneal dialysis. 14. 15. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal onoctic pressure. b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. c. Decreased renin-angiotensin response related to an increase in renal blood flow. d. Decreased portacaval pressure with greater collateral circulation. B Explanation: In cirrhosis, the liver's ability to produce albumin is compromised, leading to hypoalbuminemia. This causes a decrease in colloidal oncotic pressure, allowing fluid to leak into the interstitial spaces and leading to edema and ascites. 15. 16. When providing care for an unconscious client who has seizures. Which nursing intervention is most essential? a. Maintain the client in a semi-Fowler's position. b. Keep the room at a comfortable temperature. c. Ensure oral suction is available. d. Provide frequent mouth care. C Explanation: Ensuring that oral suction is available is essential for an unconscious client who has seizures. Suctioning can help to maintain a patent airway and prevent aspiration of secretions during and after a seizure. 16. 17. A client presents to the emergency department reporting chest pain that is radiation to the left arm, shortness of breath, and diaphoresis. Which medication D Explanation: Morphine is commonly used to treat chest pain associated with 6 / 23 BSN 266 HESI Study online at should the nurse anticipate being prescribed by the healthcare provider? a. Fentanyl. b. Hydromorphone. c. Oxycodone. d. Morphine. myocardial infarction (heart attack) as it provides pain relief, reduces anxiety, and has a vasodilatory effect that can improve blood flow to the heart. The other medications listed are not typically the first choice for managing chest pain related to a heart attack. 17. 18. An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurses to provide this client? a. Maintain prescribed eye drop regimen. b. Eat a diet high in carotene. c. Wear prescription glasses. d. Avoid frequent eye pressure measurement. A Explanation: Maintaining a prescribed eye drop regimen is crucial for managing glaucoma and preventing further vision loss. While the other suggestions might be helpful for overall eye health, adherence to the prescribed eye drop regimen is the most important action to help prevent the progression of glaucoma. 18. 20. Which information should the nurse include on the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? a. Adjust food intake to three full meals per day and no snacks. b. Sleep without pillows at night to maintain neck alignment. c. Minimize symptoms by wearing loose, comfortable clothing. C Explanation: Wearing loose, comfortable clothing can help minimize GERD symptoms by reducing pressure on the abdomen and lower esophageal sphincter. Other lifestyle changes, such as smaller, 7 / 23 BSN 266 HESI Study online at d. Avoid participation in any aerobic exercise programs. more frequent meals, elevating the head of the bed, and avoiding foods that trigger symptoms, are also important for managing GERD. 19. 21. A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? a. Move into airborne isolation. b. Collect specimens for blood cultures. c. Arrange transport for radiographic imaging. d. Obtain a sputum sample. A Explanation: The client's symptoms (intermittent fever, night sweats, productive cough with blood) are suggestive of tuberculosis (TB). The nurse should prioritize placing the client in airborne isolation to prevent the potential spread of TB to others while awaiting further assessment and testing. 20. 22. A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.) 167mL 21. 23. A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? a. Hydration of affected dry skin areas. b. Reduced pain in eczematous areas. c. Decreased weeping of ulcerations in affected areas. A Explanation: Urea cream is a moisturizing agent that helps hydrate and soften dry, rough skin in clients with eczema. The expected therapeutic response 8 / 23 BSN 266 HESI Study online at d. Healing with a return to normal skin appearance. would be hydration of the affected dry skin areas. While the cream may also help alleviate some symptoms, such as itching or pain, its primary purpose is to moisturize the skin. 22. 24. The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Activity level of bowel sounds. b. Eating patterns of dietary intake. c. Level and amount of physical activity d. Color and consistency of feces. B Explanation: In clients with chronic pancreatitis, the nurse should assess eating patterns of dietary intake to help manage persistent abdominal pain. The pain is often related to the type and amount of food consumed, and adjusting the diet can help alleviate discomfort. Clients are usually advised to eat smaller, more frequent meals, and avoid high-fat foods. 23. 25. A client with hyperparathyroidism reports a sudden monster of severe flank pain. Which intervention should the nurse include in the client's plan of care? a. Implement seizure precautions. b. Initiate cardiac telemetry. c. Administer a PRN dose of a laxative. d. Begin straining all urine. D Explanation: Sudden onset of severe flank pain in a client with hyperparathyroidism may indicate the presence of kidney stones. The nurse should include straining all urine in the client's plan of care to collect any passed 9 / 23 BSN 266 HESI Study online at stones for analysis and to monitor the progress of stone passage. 24. 26. After falling down the basement steps, a client is brought to the emergency room. X-ray confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? C Explanation: A pale right foot with sluggish capillary refill following the application of a leg cast may indicate compromised blood flow to the extremity, which requires immediate intervention by the nurse. The other findings are expected after a fracture and cast application, but do not warrant immediate intervention. 25. 27. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Apply a tight flow venturi mask. b. Encourage client to drink water. c. Assist client to an upright position. d. Administer a prescribed sedative. C 26. 28. Which action should the nurse implement to reduce the risk of vesicant extravasation in NJ the client who is receiving intravenous chemotherapy? a. Monitor the client's intravenous site hourly during the treatment. b. Keep the head of the bed elevated until the A Explanation: To reduce the risk of vesicant extravasation, the nurse should monitor the client's intravenous site hourly during the 10 / 23 BSN 266 HESI Study online at treatment is completed. c. Instruct the client to drink plenty of fluids during the treatment. d. Administer an antiemetic before starting the chemotherapy. chemotherapy treatment. This allows for early detection of infiltration or extravasation, which can minimize tissue damage. 27. 29. The home health nurse provides teaching about self-injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? (Please view the video to select the option that applies. To repeat the video, click the play button again.) a. Continue with the insulin injection. b. Keep the skin flat rather than bunched. c. Lie down flat for better skin exposure. d. Select a different injection site. A 28. 30. A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? a. Determine if the client is using an inhaler before exercising. b. Teach client to use pursed lip breathing when episodes occur. c. Review the client's routine asthma management prescriptions. d. Assess client for signs and symptoms of upper airway infection. A Explanation: Clients with exercise-induced asthma often benefit from using a shortacting bronchodilator before exercising. The nurse should determine if the client is using an inhaler before exercising to help prevent bronchoconstriction and increased mucous production. 29. 31. A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lowD Explanation: The client's symptoms of 11 / 23 BSN 266 HESI Study online at er back pain. Which intervention should the nurse implement first? a. Palpate the right flank for tenderness. b. Test her urine for the presence of hematuria c. Evaluate the urine for a strong odor. d. Measure her temperature and pulse rate. urinary frequency, burning, and right lower back pain may indicate a urinary tract infection (UTI) with possible involvement of the kidneys. The nurse should first measure the client's temperature and pulse rate to assess for signs of systemic infection 30. 32. An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breathe/minute. blood pressure 168/100 mmHg, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to treatment? Select at that apply. a. Oxygen saturation. b. Pain scale. c. Lung sounds. d. Urinary output. e. Skin elasticity. ACD Explanation: To determine the client's response to furosemide, the nurse should assess oxygen saturation (to evaluate improvements in gas exchange), lung sounds (to identify any reduction in wheezes and crackles), and urinary output (to monitor diuresis, as furosemide is a diuretic). 31. 33. While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. White blood cell (WBC) count. b. Hematocrit. A Explanation: The presence of purulent drainage at the burn wound site may indicate infection. The nurse should review the client's white blood cell (WBC) count, as an 12 / 23 BSN 266 HESI Study online at c. Platelet count. d. Blood pH level. elevated WBC count is often associated with infection. 32. 34. The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. Red blood cell count. b. Platelet count. c. White blood cell count. d. Hemoglobin levels. B Explanation: Petechiae and ecchymosis are often associated with low platelet counts, which can lead to impaired clotting and increased bleeding risk. The nurse should review the client's platelet count to assess for thrombocytopenia, which may be the cause of the observed skin findings. 33. 35. A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for the continuous bladder irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots in the tubing collection bag. Which action should the nurse take? a. Monitoring catheter drainage. Right answer for HESI b. Irrigation the catheter manually. Right answer for EAQ c. Decreasing the flow rate. d. Discounting infusing solution. A 34. 36. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle A Explanation: Since the client is on heparin therapy, 13 / 23 BSN 266 HESI Study online at collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? a. Notify the healthcare provider of the client's medication history. b. Observe the heparin injections sites for signs of bruising. c. Have the client sign the surgical and transfusion permits. d. Ensure that the potential for bleeding is explained to the client. there is an increased risk of bleeding during surgery. It is crucial for the nurse to notify the healthcare provider of the client's medication history so that appropriate precautions can be taken during surgery. 35. 37. An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and its determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. Approaches to conserve energy. b. Guidelines for oxygen use. c. Methods for weight loss. d. Strategies for smoking cessation. B Explanation: The client is being discharged with oxygen therapy, so it is most important for the nurse to emphasize guidelines for oxygen use, including safety measures, proper administration, and monitoring. While other topics like energy conservation, weight loss, and smoking cessation are important, the priority in this situation is to ensure that the client knows how to use the prescribed oxygen therapy safely and effectively. 14 / 23 BSN 266 HESI Study online at 36. 38. The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headache or trauma. Which intervention should the nurse should perform in the immediate management of the client? a. Place an indwelling urinary catheter and measure strict output. b. Notify the stroke team to assist with acute assessment and management. c. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. d. Begin continuous observation for transient episodes of neurologic dysfunction. B Explanation: The client's sudden onset of a severe headache, facial numbness, uneven smile, and weaker hand grasp on one side may indicate a stroke. The nurse should notify the stroke team immediately to begin the acute assessment and management of the client's condition. 37. 39. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. Aching feet may be soaked in lukewarm water for one hour or more. b. Shoes should be worn outside the house, but it is fine to be barefoot inside. c. Family members can help with regular foot exams. d. Heating pads are useful if on the lowest setting. C Explanation: Clients with diabetes mellitus and peripheral neuropathy are at risk for foot complications. It is important for the client to perform regular foot exams, and enlisting the help of family members can ensure that any issues are identified promptly. The other options are not recommended, as they may increase the risk of injury or infection. 15 / 23 BSN 266 HESI Study online at 38. 40. Four days following and abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? a. Wrap the feet with warmed blankets. b. Elevate extremities on pillows. c. Assess pulses with a vascular Doppler. d. Evaluate edema for pitting. C Explanation: If pedal pulses are not palpable, the nurse should use a vascular Doppler to assess the pulses more accurately. This can provide information on the adequacy of blood flow to the extremities and help identify any potential complications related to the abdominal aortic aneurysm repair. 39. 41. The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL". How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round the nearest tenth.) 0.4 40. 42. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. b. Medicate for pain and monitor vital signs according to protocol. C Explanation: The client's vital signs indicate tachycardia and tachypnea, which may be signs of hypovolemia or inadequate perfusion. Administering a prescribed intravenous fluid bolus can help address this issue and stabilize the client's vital signs. While other interventions may be nec16 / 23 BSN 266 HESI Study online at c. Administer intravenous fluid bolus as prescribed by the healthcare provider. d. Encourage the client to splint the incision with a pillow to cough and deep breathe. essary, addressing the potential hypovolemia is the most important initial step. 41. 43. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? a. Inappropriate laughter. b. Weakened cough effort. c. Asymmetrical weakness. d. Increasing anxiety. B Explanation: In a client with ALS, a weakened cough effort may indicate a decline in respiratory function, which can lead to respiratory complications or failure. Immediate intervention is necessary to address respiratory issues and prevent further complications. Other symptoms, such as inappropriate laughter, asymmetrical weakness, and increasing anxiety, are common in ALS but are less urgent in this context. 42. 44. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? a. Assesses the client's radical pulses and capillary refill time. b. Discuss approaches to chronic pain control with the client. B Explanation: Heberden's nodes are bony enlargements that can occur in degenerative joint disease and can be painful for the client. The nurse should discuss approaches to 17 / 23 BSN 266 HESI Study online at c. Notify the healthcare provider of the finding immediately. d. Review the client's dietary intake of high-protein foods. chronic pain control with the client to help manage this symptom. Assessing radial pulses, notifying the healthcare provider immediately, and reviewing dietary intake are not the most appropriate actions in this situation. 43. 45. A client with draining skin lesions of the lover extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.) a. Explain the purpose of a low bacteria diet. b. Monitor the client's white blood cell count. c. Send wound drainage for culture and sensitivity. d. Use standard precautions and wear a mask. e. Institute contact precautions for staff and visitors. BCE Explanation: Monitoring the client's white blood cell count can help assess the severity of the infection and response to treatment. Sending wound drainage for culture and sensitivity will help identify the causative organism and guide appropriate antibiotic therapy. Instituting contact precautions for staff and visitors will prevent the potential spread of MRSA. A low bacteria diet is not necessary in this situation, and using standard precautions with a mask is insufficient for preventing the spread of MRSA 44. 46. The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a B 18 / 23 BSN 266 HESI Study online at client who was exposed to the virus eight days ago. The client is experiencing fever, cough and shortness of breath. Which action is most important for the nurse to take? a. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient. b. Move the client to a private room, keep the door closed, and initiate droplet precautions. c. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results. d. Assist the client to recall everyone possibly exposed since onset symptoms. Explanation: In order to minimize the risk of transmission of COVID-19 to other patients and staff, it is important to isolate the client in a private room with the door closed and initiate droplet precautions. Wh