A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

Airborne

Protective

Contact

Droplet

Answer and Explanation

The Correct Answer is C

A reason:

Airborne precautions are not required for VRE. These precautions are used for infections transmitted through the air, such as tuberculosis, which is not the case with VRE.

B reason:

Protective precautions (also known as neutropenic or reverse precautions) are used to protect immunocompromised patients from infections. They are not appropriate for preventing the spread of VRE.

C reason:

Contact precautions are correct. VRE is typically transmitted through direct or indirect contact with contaminated surfaces or infected body fluids. Contact precautions help prevent the spread of VRE to other patients and healthcare workers.

D reason:

Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. VRE is not transmitted in this manner, so droplet precautions are not necessary.

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Correct Answer is D

Explanation

A reason:

Using each cleansing wipe twice is not correct procedure. Cleansing wipes should be used once and then discarded to maintain cleanliness and avoid contamination of the sample.

B reason:

Urinating a little and then stopping is part of the procedure, but the client should also understand the importance of cleansing. While stopping the stream initially is correct, it is not sufficient alone without proper cleansing.

C reason:

Cleaning the inside of the container with a wipe is incorrect. The inside of the container should remain sterile, and cleaning it with a wipe could introduce contaminants. The container is designed to be clean and sterile inside.

D reason:

Using the cleansing wipe from front to back is correct. This method ensures that bacteria from the anal area do not contaminate the urethral opening, which helps to collect a clean midstream urine sample.

A. pH 1-4 B. pH 5-7 C. pH 8-10 D. pH 11-14

Correct Answer is A

Explanation

A reason:

A pH reading of 1-4 is expected for gastric contents. This acidic range indicates that the NG tube is correctly placed in the stomach, where gastric secretions have a low pH due to hydrochloric acid.

B reason:

A pH reading of 5-7 is more indicative of respiratory secretions or the contents of the small intestine, not the stomach. This range suggests that the NG tube may be incorrectly placed.

C reason:

A pH reading of 8-10 is too alkaline for gastric contents and indicates incorrect tube placement. This range could suggest the presence of intestinal or respiratory secretions, not gastric.

D reason:

A pH reading of 11-14 is highly alkaline and unlikely to be encountered in clinical practice for this purpose. Such a high pH is not compatible with gastric contents and suggests a significant error or contamination in the test.

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A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure?

Correct Answer is D

Explanation

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

Correct Answer is A

Explanation

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