Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for musculoskeletal assessment during hospital…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for musculoskeletal assessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. Which infection-prevention action is essential?
Question
A. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
B. Wear gloves only and skip hand hygiene when leaving the room.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
B. Wear gloves only and skip hand hygiene when leaving the room.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
Rationale
Correct answer: A. 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.