Level: Advanced
Difficulty: Hard
Subtopic: Sleep and rest
NCLEX: A 55-year-old client after abdominal surgery is being evaluated for nursing care related to sleep and rest. Asses…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 55-year-old client after abdominal surgery is being evaluated for nursing care related to sleep and rest. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
Rationale
Correct answer: B. 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.