Level: Foundational
Difficulty: Easy
Subtopic: Reservoirs and modes of transmission
NCLEX: A 44-year-old client in airborne isolation is being evaluated for nursing care related to reservoirs and modes of…
Microbiology Safety and Infection Prevention and Control
Case Study
A 44-year-old client in airborne isolation is being evaluated for nursing care related to reservoirs and modes of transmission. Assessment data include fever 101.8°F (38.8°C) with elevated WBC and bandemia. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that fever 101.8°F (38.8°C) with elevated WBC and bandemia.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that fever 101.8°F (38.8°C) with elevated WBC and bandemia.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that fever 101.8°F (38.8°C) with elevated WBC and bandemia.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.