A client with a possible vancomycin-resistant enterococci (VRE) infection is admitted with purulent drainage from an abdominal surgical incision.
What nursing interventions should be included in the plan of care? Select all that apply.
Send wound drainage for culture and sensitivity.
Explain the purpose of a low bacteria diet.
Use standard precautions and wear a mask.
Institute contact precautions for staff and visitors.
Monitor the client’s white blood cell count.
Correct Answer : A,C,D,E
Choice A rationale
Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.
Choice B rationale
There is no specific “low bacteria diet” recommended for VRE infections20.
Choice C rationale
Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.
Choice D rationale
Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.
Choice E rationale
Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.
Choice B rationale
Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.
Choice C rationale
While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.
Choice D rationale
Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.
Correct Answer is C
Explanation
Choice A rationale
Buttered whole wheat toast and coffee are not the best options for a patient with diarrhea. Whole wheat toast is high in fiber, which can exacerbate diarrhea. Coffee is a diuretic and can lead to further dehydration, which is a risk with diarrhea.
Choice B rationale
Granola is high in fiber and can worsen diarrhea. Strawberries, while a good source of vitamins, are also high in fiber. Tea can be dehydrating, which is not ideal when dealing with diarrhea.
Choice C rationale
Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system.
Choice D rationale
Sausage is high in fat, which can worsen diarrhea. Eggs, while a good source of protein, can be hard to digest for some people and may not be the best choice during a bout of diarrhea. Milk is a common allergen and can cause digestive issues in people who are lactose intolerant.
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