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.

Choice A rationale

Canned chicken broth with barley is not the best choice for a patient with hypertension. Canned foods, including chicken broth, are often high in sodium, which can raise blood pressure.

Choice B rationale

Tomato juice and gluten-free crackers may seem like a healthy option, but tomato juice can be high in sodium. While gluten-free crackers can be part of a healthy diet, they don’t offer any specific benefits for controlling hypertension.

Choice C rationale

A plain baked sweet potato is an excellent choice for a patient with hypertension. Sweet potatoes are high in potassium, which can help lower blood pressure. They’re also a good source of fiber and are naturally low in sodium.

Choice D rationale

Dill pickles and black olives are both high in sodium, which can raise blood pressure. Therefore, they’re not a good choice for someone with hypertension.

Choice A rationale

Setting up supplemental oxygen delivery is not the immediate action the nurse should take. The patient’s FiO2 is currently at 35%, which is within the normal range.

Choice B rationale

Increasing the fraction of inspired oxygen is not necessary at this time. The patient’s current FiO2 is within the normal range.

Choice C rationale

The nurse should gather supplies for extubation. As the patient is due to start ventilator weaning, preparing for extubation is the next logical step. This involves having all necessary equipment and personnel ready for the procedure.

Choice D rationale

Placing a nasogastric tube is not the immediate action the nurse should take. While a nasogastric tube can be used to provide nutrition and medication, it is not directly related to the process of ventilator weaning.