Level: Advanced
Difficulty: Hard
Subtopic: Sepsis pathophysiology basics
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for nursing care related to sepsis pathophys…
Microbiology Clinical Judgment 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 sepsis pathophysiology basics. Assessment data include fever 101.8°F (38.8°C) with elevated WBC and bandemia. Using the clinical judgment model, what is the nurse's first step?
Question
A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Implement the first intervention on the existing care plan without reviewing new data.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: A. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.