medium · NCLEX-RN safety
An admitting nurse reviews the medical record of an 84-year-old male transferred from a long-term care facility for rehabilitation after a left hip hemiarthroplasty. A review of transfer documents reveals that the client was identified as colonized with vancomycin-resistant Enterococcus (VRE) in his stool during a facility-wide screening three weeks ago. He is continent of stool, has a clean and dry surgical incision, and has no invasive lines or catheters. Vital signs: BP 124/76 mmHg, HR 72/min, RR 16/min, T 36.9 C (98.4 F).
Which action should the nurse take first?
- Place the client on Airborne Precautions in a negative-pressure room due to the high environmental persistence of VRE.
- Keep the client in a standard semi-private room with a non-isolated roommate since he has no active drainage or incontinence.
- Place the client in a private room or cohort him with another VRE-colonized client and initiate Contact Precautions.
- Administer prophylactic oral vancomycin 125 mg every 6 hours as ordered to decolonize his gastrointestinal tract.
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