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Difficulty: MediumStandard and Transmission-Based Precautions

A nurse assumes care for a postoperative client who just arrived from the surgical recovery room after an exploratory laparotomy. The client has an active Vancomycin-resistant Enterococcus (VRE) infection in the peritoneal cavity and multiple surgical drains in place. Which of the following actions should the nurse implement? Select all that apply.

  1. Place the client in a private room with a designated bathroom or bedside commode.Answer
  2. Wear a face shield and a surgical mask when emptying the client's surgical drains.Answer
  3. Leave a dedicated stethoscope and blood pressure cuff inside the client's room for exclusive use.Answer
  4. D
    Assess the client's surgical dressing for VRE containment before evaluating their respiratory status and vital signs.
  5. E
    Delegate the task of evaluating the surgical incision for signs of active infection to the unlicensed assistive personnel (UAP).
  6. F
    Maintain the client in an airborne infection isolation room (AIIR) with negative-pressure airflow.

Answer

The correct actions are placing the client in a private room, wearing splash protection when emptying drains, and using dedicated equipment.
VRE requires Contact precautions, which mandate a private room and dedicated equipment to prevent transmission via touch. Furthermore, standard precautions dictate that protective eyewear and a mask must be worn during procedures likely to generate splashes, such as emptying surgical drains.

Step-by-Step Solution

1
Identify the primary pathogen and its mode of transmission.
The client has Vancomycin-resistant Enterococcus (VRE), which is transmitted via direct and indirect contact.
Determining the transmission route dictates the appropriate isolation tier (Contact precautions).
2
Determine the required environment and equipment for Contact precautions.
A private room and dedicated patient-care equipment (stethoscope, blood pressure cuff) are necessary.
These measures prevent the transfer of the pathogen to other vulnerable clients.
3
Evaluate the specific nursing tasks for additional risk factors.
Emptying surgical drains presents a risk for fluid splashes.
Standard precautions apply to all clients, requiring nurses to add a mask and eye protection whenever body fluid splashing is anticipated.
4
Apply prioritization and delegation rules to the scenario.
Physiological stability (ABCs) takes precedence over infection control checks, and clinical assessment cannot be delegated.
The RN must prioritize airway and breathing in a postoperative client and must personally perform all wound assessments.

Key Concept

Standard and Transmission-Based Precautions (Contact) paired with Prioritization and Delegation.
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Standard and Transmission-Based Precautions

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