Level: Advanced
Difficulty: Hard
Subtopic: Sterile technique
NCLEX: A 44-year-old client in airborne isolation is being evaluated for nursing care related to sterile technique. Asse…
Microbiology Clinical Judgment Safety and Infection Prevention and Control
Case Study
A 44-year-old client in airborne isolation is being evaluated for nursing care related to sterile technique. Assessment data include isolation precautions ordered for confirmed pulmonary tuberculosis. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Evaluate discharge readiness before addressing acute findings.
C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: C. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.