Level: Advanced
Difficulty: Hard
Subtopic: Priority setting
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to priority setting….
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to priority setting. 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. 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.