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 B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. Give the client 4 ounces (120 mL) of orange juice. B. Administer a PRN dose of regular insulin. C. Provide the client with 1/2 cup (120 mL) diet carbonated soda. D. Check the client's current fingerstick blood glucose. E. Obtain blood pressure and pulse rate.

Correct Answer is ["A","D","E"]

Explanation

A. Giving the client 4 ounces of orange juice can quickly raise blood glucose levels if hypoglycemia is suspected.

B. Administering insulin is inappropriate without knowing the current blood glucose level, especially if hypoglycemia is suspected.

C. Diet carbonated soda does not contain sugar and will not help raise blood glucose levels.

D. Checking the client's fingerstick blood glucose is essential to determine if hypoglycemia is causing the symptoms.

E. Obtaining blood pressure and pulse rate is important to assess the client's overall condition and identify any additional complications.

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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.

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Correct Answer is B

Explanation

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Correct Answer is ["A","D","E"]

Explanation

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