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 C
Explanation
Choice A rationale
Increased BUN and serum creatinine are not typically symptoms of mononucleosis. These laboratory findings are more commonly associated with kidney dysfunction.
Choice B rationale
Ear pain and fever can be symptoms of many illnesses, including mononucleosis. However, they are not the most specific symptoms of this condition.
Choice C rationale
A positive Epstein-Barr virus test and malaise are common symptoms of mononucleosis. The Epstein-Barr virus is the most common cause of mononucleosis.
Choice D rationale
Elevated WBC and sedimentation rate can be seen in many inflammatory or infectious conditions, including mononucleosis. However, they are not the most specific symptoms of this condition.
Correct Answer is D
Explanation
Choice A rationale
While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.
Choice B rationale
Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.
Choice C rationale
Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.
Choice D rationale
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.
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