Level: Foundational
Difficulty: Easy
Subtopic: Reservoirs and modes of transmission
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for nursing care related to reservoirs and m…
Microbiology Safety and Infection Prevention and Control
Case Study
A 71-year-old client in a long-term care facility is being evaluated for nursing care related to reservoirs and modes of transmission. Assessment data include productive cough for 2 weeks with night sweats and hemoptysis. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Complete nonurgent tasks first because the client appears calm.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Complete nonurgent tasks first because the client appears calm.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.