A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.
Use standard precautions and wear a mask.
Institute contact precautions for staff and visitors.
Explain the purpose of a low bacteria diet.
Monitor the client's white blood cell count.
Send wound drainage for culture and sensitivity.
Correct Answer : B,D,E
A. Standard precautions are important, but VRE requires contact precautions due to its highly transmissible nature. A mask is not specifically required unless there are respiratory symptoms.
B. Contact precautions are essential for preventing the spread of VRE and should be instituted for staff and visitors.
C. A low bacteria diet is not necessary for VRE infections; it is more relevant for immunocompromised patients.
D. Monitoring the white blood cell count helps assess the infection's progression and the body's response.
E. Sending wound drainage for culture and sensitivity is crucial for identifying the specific pathogen and determining appropriate antibiotic treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The nurse should call for an assistant to take over the tracheostomy care so the nurse can respond to the code blue.
B. Closing the room door is not an appropriate response in this emergency situation.
C. Finishing the procedure would delay the nurse’s response to the code blue, which is urgent.
D. Responding to the code is crucial, but the nurse should ensure the client's tracheostomy care is continued by calling for assistance first.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Select Response 1: First thing in the morning fasting
Monitoring blood glucose levels first thing in the morning while fasting helps assess the client’s baseline glucose level after an overnight fast. This is important for evaluating overall glucose control and adjusting treatment if necessary.
Select Response 2: Prior to each meal
Checking blood glucose levels before each meal provides insight into how well the client’s blood sugar is controlled throughout the day and helps adjust dietary and medication plans to maintain optimal glucose levels.
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