Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 49-year-old client in the emergency department is being evaluated for skin and wound assessment during hospital…
Health assessment Reduction of Risk Potential
Case Study
A 49-year-old client in the emergency department is being evaluated for skin and wound assessment during hospitalization. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. 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. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale
Correct answer: D. 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.