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 fever 101.8°F (38.8°C) with elevated WBC and bandemia. 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. Routine data unchanged from the prior assessment.
D. The new finding that fever 101.8°F (38.8°C) with elevated WBC and bandemia.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that fever 101.8°F (38.8°C) with elevated WBC and bandemia.
Rationale
Correct answer: D. The new finding that fever 101.8°F (38.8°C) with elevated WBC and bandemia.
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.