Level: Advanced
Difficulty: Hard
Subtopic: Emergency deterioration
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for rapidly worsening vital signs. Assessment dat…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for rapidly worsening vital signs. Assessment data include surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
D. Skip precautions if the client has no fever.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
D. Skip precautions if the client has no fever.
Rationale
Correct answer: C. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.