A nurse is caring for a client who has a wound infection that contains vancomycin-resistant Enterococcus (VRE). Which of the following types of precautions should the nurse plan to take while caring for this client?
Airborne
Droplet
Protective environment
Contact
The Correct Answer is D
Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.
Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.
Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.
Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Clean gloves are necessary when touching or being in close proximity to any wound, especially one that is infected with MRSA. MRSA is a highly contagious bacterium that can spread through direct contact with the infected area or through indirect contact with contaminated objects. Wearing clean gloves helps prevent the transmission of MRSA to the nurse and to other patients.
Choice B reason: Protective eyewear is not typically required for checking a patient's pulse. However, if there is a risk of splashing or spraying of bodily fluids, protective eyewear becomes necessary to protect the mucous membranes of the eyes from exposure to infectious materials.
Choice C reason: Sterile gloves are used during procedures that require an aseptic technique, such as the changing of a sterile dressing or during invasive procedures. Checking a patient's pulse does not require sterile gloves, as it is not an aseptic procedure.
Choice D reason: A surgical mask should be worn if there is a risk of droplet transmission or if the nurse will be in close contact with the patient's wound. MRSA can be present in nasal secretions and can be spread by droplets, so wearing a mask can provide an additional layer of protection against the transmission of MRSA.
Correct Answer is A
Explanation
Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.
Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.
Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.
Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.
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