Level: Foundational
Difficulty: Easy
Subtopic: Shock states
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to shock states. Assessm…
Pathophysiology Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to shock states. Assessment data include blood glucose 420 mg/dL with acetone breath and Kussmaul respirations. Which infection-prevention action is essential?
Question
A. Wear gloves only and skip hand hygiene when leaving the room.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
B. Use sterile technique for all routine hygiene regardless of diagnosis.
C. Skip precautions if the client has no fever.
D. Perform hand hygiene and apply the transmission-based precautions indicated by the client's diagnosis.
Rationale
Correct answer: D. 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.