Level: Advanced
Difficulty: Hard
Subtopic: Sepsis pathophysiology basics
NCLEX: A 44-year-old client in airborne isolation is being evaluated for nursing care related to sepsis pathophysiology…
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 sepsis pathophysiology basics. Assessment data include wound culture grows MRSA with spreading erythema. 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. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: C. 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.