Level: Advanced
Difficulty: Hard
Subtopic: Sterile technique
NCLEX: A 71-year-old client in a long-term care facility is being evaluated for nursing care related to sterile techniqu…
Microbiology Safety and Infection Prevention and Control
Case Study
A 71-year-old client in a long-term care facility is being evaluated for nursing care related to sterile technique. Assessment data include productive cough for 2 weeks with night sweats and hemoptysis. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that productive cough for 2 weeks with night sweats and hemoptysis.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that productive cough for 2 weeks with night sweats and hemoptysis.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that productive cough for 2 weeks with night sweats and hemoptysis.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.