Level: Foundational
Difficulty: Easy
Subtopic: Normal flora and opportunistic infection
NCLEX: A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to normal flora and o…
Microbiology Safety and Infection Prevention and Control
Case Study
A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to normal flora and opportunistic infection. Assessment data include watery diarrhea 8 times today after antibiotic therapy. Which nursing action is the priority to keep the client safe?
Question
A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Leave the client alone to promote independence while finishing charting.
C. Apply the first intervention in the policy manual without a current assessment.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: A. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.