Level: Foundational
Difficulty: Easy
Subtopic: Hydration and fluid balance
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to hydration and flui…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to hydration and fluid balance. Assessment data include the client has 6% unintentional weight loss in 1 month and albumin 2.8 g/dL. Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
C. Use sterile technique for all routine hygiene regardless of diagnosis.
D. Skip precautions if the client has no fever.
Rationale
Correct answer: B. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Infection control matches the pathogen route: hand hygiene plus appropriate precautions for contact, droplet, or airborne transmission.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.