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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Osteoarthritis is primarily caused by the destruction of joint cartilage, which leads to pain, stiffness, and decreased mobility in the affected joints. This degenerative process is the hallmark of the condition.

B. Loss of bone mineral density is associated with osteoporosis, not osteoarthritis. While both conditions can cause joint pain, they have different underlying pathologies.

C. An infectious process in the synovial fluid would indicate septic arthritis, which is an acute and severe condition requiring different management.

D. A systemic inflammatory response is more characteristic of rheumatoid arthritis, an autoimmune condition, rather than osteoarthritis, which is a degenerative joint disease.

A. Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C) B. Start a peripheral IV C. Chest x-ray D. NPO E. Start oxygen 3 L/minute via nasal cannula F. Sputum culture G. Place the client on a cardiorespiratory monitor H. Run 0.9% sodium chloride IV infusion at 150 mL/hour

Correct Answer is ["B","E"]

Explanation

A. Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C): While managing fever is important, it is not as immediate a priority as ensuring the client's breathing and hydration.

B. Start a peripheral IV: Establishing a peripheral IV line is crucial for administering medications and fluids. This is essential for the client's hydration and potential intravenous medication needs.

C. Chest x-ray: Although a chest x-ray is important for diagnosing the cause of the symptoms, it can be done after the client’s immediate needs for oxygen and IV access are addressed.

D. NPO: Keeping the client NPO is necessary, but it doesn't require immediate action compared to oxygenation and IV access.

E. Start oxygen 3 L/minute via nasal cannula: The client is experiencing difficulty breathing, so providing supplemental oxygen is a priority to ensure adequate oxygenation and alleviate respiratory distress.

F. Sputum culture: Obtaining a sputum culture is important for diagnosis, but it can wait until after the client is stabilized with oxygen and IV access.

G. Place the client on a cardiorespiratory monitor: Monitoring the client's cardiac and respiratory status is important, but ensuring oxygenation and IV access takes precedence.

H. Run 0.9% sodium chloride IV infusion at 150 mL/hour: While starting the IV infusion is important, it follows the establishment of the IV line and oxygen administration.

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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.

Nursing Test Bank

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An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

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Explanation

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Correct Answer is ["B","E"]

Explanation

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