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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.

This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.

A. Auscultate an area six inches below the umbilicus. B. Observe the appearance of the patient’s urine. C. Palpate the area above the pubic symphysis. D. Measure the girth of the patient’s lower abdomen.

Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

Correct Answer is A

Explanation

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

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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.