A client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has been admitted with a possible vancomycin-resistant enterococci (VRE) infection. What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Use standard precautions and wear a mask.

Monitor the client's white blood cell count.

Send wound drainage for culture and sensitivity.

Explain the purpose of a low bacteria diet.

Institute contact precautions for staff and visitors.

Answer and Explanation

Correct Answer : B,C,E

A. Using standard precautions and wearing a mask are generally used for preventing the spread of infections but are not specific to VRE, which requires contact precautions.
B. Monitoring the client's white blood cell count is important for assessing the severity of the infection and the body’s response to it, which is crucial for ongoing management.
C. Sending wound drainage for culture and sensitivity is essential for identifying the causative pathogen and determining the most effective treatment, especially given the suspected VRE infection.
D. A low bacteria diet is more relevant for immunocompromised clients or those undergoing specific treatments, and it is not a primary intervention for managing VRE.
E. Instituting contact precautions for staff and visitors is necessary to prevent the spread of VRE, as VRE is transmitted through direct or indirect contact.

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Correct Answer is A

Explanation

A. Drinks more fluids than previously: Increased thirst and fluid intake are common symptoms of type 1 diabetes due to high blood glucose levels causing osmotic diuresis. This is a classic sign of diabetes that parents would likely report.
B. Refuses to eat favorite meals at home: While changes in eating habits can occur, this is not a typical initial symptom of type 1 diabetes. The increased thirst and urination are more characteristic of the disease.
C. Voids only one or two times per day: In type 1 diabetes, increased urination (polyuria) occurs rather than reduced frequency of urination. Therefore, this is not a symptom of type 1 diabetes.
D. Gained 10 lb (4.5 kg) within one month: Rapid weight gain is not typical of type 1 diabetes. In fact, children with type 1 diabetes often experience weight loss despite increased appetite.

A. Metabolic alkalosis. B. Respiratory acidosis. C. Metabolic acidosis. D. Respiratory alkalosis.

Correct Answer is D

Explanation

A. Metabolic alkalosis: This condition is typically caused by an increase in bicarbonate or a loss of hydrogen ions, often due to vomiting or excessive use of antacids. It is not commonly associated with hyperventilation.
B. Respiratory acidosis: This condition results from CO₂ retention due to inadequate ventilation, which is the opposite of hyperventilation. The adolescent’s hyperventilation indicates CO₂ loss rather than retention.
C. Metabolic acidosis: This condition is characterized by a decrease in bicarbonate or an increase in acid production, which does not align with the hyperventilation observed in this scenario.
D. Respiratory alkalosis: Hyperventilation leads to excessive CO₂ exhalation, causing a decrease in CO₂ levels in the blood and resulting in respiratory alkalosis. This is the expected acid-base imbalance due to the adolescent’s anxiety and hyperventilation.

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A client with purulent discharge from a venous ulcer that has been unsuccessfully treated with intravenous vancomycin has been admitted with a possible vancomycin-resistant enterococci (VRE) infection. What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?

Correct Answer is A

Explanation

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

Correct Answer is D

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

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