Level: Clinical
Difficulty: Medium
Subtopic: Generate solutions
NCLEX: An RN prioritizing care after a change in status is being evaluated for nursing care related to generate solution…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
An RN prioritizing care after a change in status is being evaluated for nursing care related to generate solutions. 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. 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.