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 C

Explanation

A. Decreasing expiratory pressure might not directly address the elevated PaCO2 and low pH.

B. Increasing tidal volume may help, but it’s more critical to address the ventilation rate first.

C. Increasing the rate of ventilation will help blow off more CO2, correcting the respiratory acidosis (elevated PaCO2 and low pH).

D. Decreasing expiratory flow time is less relevant than adjusting ventilation rates in this scenario.

A. Ear pain and fever. B. Positive Epstein-Barr, and malaise. C. Increased BUN and serum creatinine. D. Elevated WBC and sedimentation rate.

Correct Answer is B

Explanation

A. Ear pain and fever are not characteristic symptoms of mononucleosis.

B. Mononucleosis is often associated with a positive Epstein-Barr virus (EBV) test and symptoms of malaise, fatigue, and lymphadenopathy.

C. Increased BUN and serum creatinine indicate kidney function issues, which are not typically associated with mononucleosis.

D. While elevated WBC and sedimentation rate can occur, they are nonspecific and can be seen in many conditions; they are not defining symptoms of mononucleosis.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

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

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Correct Answer is B

Explanation

The nurse is caring for a client with type 1 diabetes mellitus who reports experiencing diaphoresis and shakiness in the early morning hours. The nurse should expect which change in the client's treatment plan?

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.

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

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Patient Data Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.