A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.
Monitor the client’s white blood cell count.
Implement contact precautions for staff and visitors.
Use standard precautions and wear a mask.
Explain the purpose of a low bacteria diet.
Send wound drainage for culture and sensitivity.
Correct Answer : A,B,E
Choice A rationale
Monitoring the client’s white blood cell count is important in this case. An elevated white blood cell count is a common sign of infection, and regular monitoring can help assess the client’s response to treatment.
Choice B rationale
Implementing contact precautions for staff and visitors is crucial when caring for a client with a potential VRE infection. VRE is a multi-drug resistant organism that can be spread through direct contact, so strict infection control measures are necessary.
Choice C rationale
Using standard precautions and wearing a mask is generally good practice in healthcare settings to prevent the spread of infections. However, a mask is not specifically required for contact precautions with VRE456.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant in this case. While diet can play a role in overall health and recovery, it is not a specific intervention for a client with a potential VRE infection.
Choice E rationale
Sending wound drainage for culture and sensitivity is an important step in confirming the presence of VRE and determining the most effective antibiotic therapy.
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Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is important in assessing overall physical health and detecting any potential neuromuscular disorders. However, in the context of a client with a history of heart failure and elevated potassium levels, this would not be the most critical intervention. High potassium levels can lead to hyperkalemia, which can cause serious heart rhythm disturbances.
Choice B rationale
Observing the color and amount of urine can provide valuable information about the client’s hydration status and kidney function. In the case of heart failure, monitoring urine output can help assess the effectiveness of diuretic therapy and the progression of the disease. However, it is not the most immediate concern given the client’s high potassium levels.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention in this scenario. A serum potassium level of 6.2 mEq/L is higher than the normal range (3.5-5.0 mEq/L) and can cause life-threatening heart rhythm abnormalities. Therefore, the nurse should prioritize assessing the client’s heart rhythm to detect any abnormalities caused by this electrolyte imbalance.
Choice D rationale
Assessing the strength of deep tendon reflexes can help identify changes in neuromuscular function and is often used in neurological assessments. However, it is not the most critical intervention in the context of elevated potassium levels and heart failure.
Correct Answer is B
Explanation
Choice A rationale
Suggesting that the child participate in a team sport to encourage socialization is not the best response. Duchenne muscular dystrophy (DMD) is a progressive disease that causes muscle weakness and loss of muscle mass. Participating in a team sport could be physically challenging for the child and could potentially lead to injury.
Choice B rationale
Encouraging the parents to allow the child to continue attending swimming lessons with supervision is the best response. Swimming is a low-impact exercise that can help maintain muscle strength and flexibility in children with DMD. It also provides an opportunity for socialization.
Choice C rationale
Explaining that the child is too young to understand the risks associated with swimming is not the best response. Children with DMD can participate in swimming with appropriate supervision and safety measures in place.
Choice D rationale
Providing a list of alternative activities that are less likely to cause the child to experience fatigue is not the best response. While it’s important to consider activities that are appropriate for the child’s physical abilities, it’s also important to consider the child’s interests. The child has expressed a desire to continue swimming, and with appropriate supervision, this activity can be beneficial.
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