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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A reason:
Decreased heart rate is not a manifestation of hypovolemia. In fact, hypovolemia typically causes an increased heart rate (tachycardia) as the body attempts to compensate for the reduced blood volume.
B reason:
Increased blood pressure is not a characteristic of hypovolemia. Hypovolemia usually results in decreased blood pressure (hypotension) due to the reduced volume of blood circulating in the body.
C reason:
A weak pulse is a common manifestation of hypovolemia. Due to the reduced blood volume, the heart may not be able to generate a strong pulse, resulting in a weak and thready pulse.
D reason:
Dyspnea, or difficulty breathing, can be associated with hypovolemia but it is not as direct a manifestation as a weak pulse. It may occur due to inadequate oxygen delivery to tissues or related conditions, but the primary signs of hypovolemia are related to blood pressure and pulse.
Correct Answer is C
Explanation
A reason:
Determining the time the client last received pain medication is important, but it should be done after assessing the current pain level. The nurse needs to know the severity of the pain to decide the next steps.
B reason:
Measuring the client's vital signs, including temperature, is also important, especially to rule out complications like infection. However, addressing the client's immediate pain should take priority to provide relief and then proceed with further assessments.
C reason:
Asking the client to rate her pain on a scale from 0 to 10 is correct. This provides a clear understanding of the pain's intensity, which is essential for determining the appropriate intervention. It allows the nurse to gauge the severity of the pain and respond accordingly.
D reason:
Repositioning the client and offering a back rub can help alleviate discomfort, but these actions should follow the pain assessment to ensure the interventions are appropriate based on the pain's severity and nature.
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