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 B

Explanation

Choice A rationale

While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.

Choice B rationale

Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.

Choice C rationale

While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

Choice D rationale

While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

A. Transfer Patient D to an isolation room 24 hours prior to surgery. B. Increase Patient A’s oxygen to 4 L/minute via nasal cannula. C. Ensure that there are two units of packed cells available for Patient B. D. Request the dietitian to include a banana in Patient C’s breakfast tray.

Correct Answer is C

Explanation

Choice A rationale

There is no indication that Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L), needs to be transferred to an isolation room 24 hours prior to surgery.

Choice B rationale

Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air, does not necessarily need an increase in oxygen. An oxygen saturation of 94% is within normal limits.

Choice C rationale

Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L), may require a blood transfusion. A hemoglobin level of 8.2 mg/dL is low, and having packed cells available is a prudent measure.

Choice D rationale

Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), has a normal potassium level. Including a banana in the breakfast tray is not a priority.

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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.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching an older client about the prevention of osteoporosis.Which foods should the nurse recommend to the client to increase in the diet?

Correct Answer is B

Explanation

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.