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?

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.

A reason:

Applying cornstarch to keep the skin dry is not recommended because it can lead to irritation and promote fungal growth. Instead, barrier creams or moisture-wicking products are more appropriate to maintain skin dryness and integrity.

B reason:

Repositioning the client every 3 hours is not frequent enough to effectively prevent skin breakdown in at-risk patients. The standard recommendation is to reposition the client every 2 hours to relieve pressure and reduce the risk of pressure ulcers.

C reason:

Massaging bony prominences is not advisable as it can cause additional trauma to the skin and underlying tissues, potentially worsening the risk of skin breakdown. Gentle repositioning and cushioning are more effective strategies.

D reason:

Providing the client with a diet high in protein is essential for maintaining skin integrity. Protein is vital for tissue repair and regeneration, and a high-protein diet supports overall skin health and resilience against breakdown.