Level: Foundational
Difficulty: Easy
Subtopic: Recognize cues
NCLEX: An RN prioritizing care after a change in status is being evaluated for unfolding changes in a case study. Assess…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for unfolding changes in a case study. Assessment data include new vital signs show blood pressure 88/50 mm Hg, heart rate 124/min, and increasing confusion. 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. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
D. Skip precautions if the client has no fever.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
D. Skip precautions if the client has no fever.
Rationale
Correct answer: C. 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.