Level: Advanced
Difficulty: Hard
Subtopic: Sepsis pathophysiology basics
NCLEX: A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to sepsis pathophysio…
Microbiology Safety and Infection Prevention and Control
Case Study
A 52-year-old client on a medical-surgical unit is being evaluated for nursing care related to sepsis pathophysiology basics. Assessment data include isolation precautions ordered for confirmed pulmonary tuberculosis. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that isolation precautions ordered for confirmed pulmonary tuberculosis.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that isolation precautions ordered for confirmed pulmonary tuberculosis.
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.