Level: Foundational
Difficulty: Easy
Subtopic: Cardiac disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for heart failure exacerbation. Assessment data i…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for heart failure exacerbation. Assessment data include sudden slurred speech and right-sided weakness began 30 minutes ago. Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
Rationale
Correct answer: B. 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.