Level: Clinical
Difficulty: Medium
Subtopic: Hypoxia and impaired gas exchange
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to hypoxia and impaired…
Pathophysiology Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include surgical incision with purulent drainage and fever 101.5°F (38.6°C). Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale
Correct answer: D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.