Level: Advanced
Difficulty: Hard
Subtopic: Delegation rules
NCLEX: A 58-year-old client on a telemetry unit is being evaluated for a busy medical-surgical assignment. Assessment da…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 58-year-old client on a telemetry unit is being evaluated for a busy medical-surgical assignment. Assessment data include new chest pain rated 8/10 with diaphoresis. 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.