Level: Advanced
Difficulty: Hard
Subtopic: Sterile technique
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for nursing care related to sterile techniqu…
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 sterile technique. Assessment data include fever 101.8°F (38.8°C) with elevated WBC and bandemia. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.