A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.
Use standard precautions and wear a mask.
Institute contact precautions for staff and visitors.
Explain the purpose of a low bacteria diet.
Monitor the client's white blood cell count.
Send wound drainage for culture and sensitivity.
Correct Answer : B,D,E
A. Standard precautions are important, but VRE requires contact precautions due to its highly transmissible nature. A mask is not specifically required unless there are respiratory symptoms.
B. Contact precautions are essential for preventing the spread of VRE and should be instituted for staff and visitors.
C. A low bacteria diet is not necessary for VRE infections; it is more relevant for immunocompromised patients.
D. Monitoring the white blood cell count helps assess the infection's progression and the body's response.
E. Sending wound drainage for culture and sensitivity is crucial for identifying the specific pathogen and determining appropriate antibiotic treatment.
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Related Questions
Correct Answer is D
Explanation
A. Elevating the legs is beneficial for venous circulation, but not for arterial circulation, which can worsen with elevation.
B. TED hose are primarily used to promote venous return and prevent deep vein thrombosis, not to enhance arterial circulation.
C. Inspecting feet daily is essential for managing diabetes-related foot complications, but it does not directly improve arterial circulation.
D. Smoking cessation is critical for improving arterial circulation as smoking is a major risk factor for peripheral artery disease. Stopping smoking can significantly enhance blood flow and reduce pain.
Correct Answer is B
Explanation
A.
In end-stage kidney failure, nephron damage is permanent and irreversible. Increasing protein does not restore kidney function.
B. Clients with end-stage kidney disease (ESKD) who are receiving dialysis require increased protein intake. Dialysis removes not only waste products but also amino acids and proteins. Without adequate protein intake, the client is at risk for malnutrition, muscle wasting, poor wound healing, and decreased energy. Therefore, protein intake is increased to replace losses and maintain nutritional status.
C. Protein restriction is appropriate in earlier stages of chronic kidney disease to reduce workload on the kidneys. However, once the client is on dialysis, protein needs increase.
D. Protein intake should be decreased to prevent the buildup of nitrogenous wastes, which the failing kidneys cannot adequately filter. Dialysis can help remove these wastes, but dietary management is still crucial.
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