A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?
Place the client in a negative pressure room.
Wear a gown and gloves during client interactions and care
Wear a surgical mask during client interactions and care
Place the client in a room with high-efficiency particulate air (HEPA) filtration for incoming air.
The Correct Answer is B
A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne diseases like tuberculosis or measles, where pathogens are airborne. VRE is a contact-transmitted infection, not airborne, so a negative pressure room is not necessary.
B. Wear a gown and gloves during client interactions and care: VRE is spread through direct contact with contaminated surfaces or bodily fluids. Wearing a gown and gloves provides the necessary precautions to prevent the spread of the infection through contact transmission.
C. Wear a surgical mask during client interactions and care: A surgical mask is primarily used for droplet precautions (e.g., influenza), not for contact precautions like VRE. A mask is not necessary unless the client has a respiratory infection or if there is a risk of splashing bodily fluids.
D. Place the client in a room with high-efficiency particulate air (HEPA) filtration for incoming air: HEPA filtration is used for airborne infections such as tuberculosis. Since VRE is not an airborne pathogen, this measure is unnecessary for preventing the spread of VRE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use a moisture barrier on the client's skin: Applying a moisture barrier cream helps protect the skin from irritation caused by constant exposure to stool and urine. It creates a protective layer that prevents breakdown, reduces friction, and maintains skin integrity in incontinent clients.
B. Clean the client's skin with soap and hot water: Using soap and hot water can strip the skin of natural oils and cause dryness or irritation, which increases the risk of breakdown. Gentle cleansing with mild soap and lukewarm water is recommended instead to preserve skin health.
C. Massage the area around the client's coccyx: Massaging bony prominences can damage fragile tissue and capillaries in older adults, increasing the risk for pressure injuries rather than preventing them. Light touch is appropriate, but firm massage should be avoided in at-risk areas.
D. Limit the client's fluid intake: Restricting fluids can lead to dehydration, concentrated urine, and an increased risk of urinary tract infections. Adequate hydration is essential to support overall health and skin resilience, even when managing incontinence.
Correct Answer is ["A","B","D"]
Explanation
- "Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
- "Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
- "Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
- "You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
- "You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.
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