Level: Advanced
Difficulty: Hard
Subtopic: Vaccination and herd protection
NCLEX: A 44-year-old client in airborne isolation is being evaluated for nursing care related to vaccination and herd pr…
Microbiology Safety and Infection Prevention and Control
Case Study
A 44-year-old client in airborne isolation is being evaluated for nursing care related to vaccination and herd protection. Assessment data include watery diarrhea 8 times today after antibiotic therapy. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Document the finding and recheck at the end of the shift without further assessment.
Rationale
Correct answer: B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.