A patient had an appendectomy three days ago and is reporting pain in the lower abdomen of 7/10. After further assessment, the nurse notes the following findings (see table below):
|
Vital Signs |
Blood Pressure: 116/72 Heart Rate: 83 beats per minute Respiratory Rate: 18 breaths per minute Temperature: 98.5F Pulse Oximetry: 99% on room air Pain: 7/10 |
|
Incision Site |
Wound edges are approximated with erythema, warmth and tenderness on palpation. Scant amount of purulent drainage on dressing. |
Based on these findings, what intervention should the nurse implement?
Administer an antibiotic.
Provide a warm water soak to the area.
Provide education about pain management
Notify the provider about the findings
The Correct Answer is D
A. Administer an antibiotic. While antibiotics may be needed, they must be ordered by the provider. The nurse should notify the provider first to evaluate for infection.
B. Provide a warm water soak to the area. Warm soaks can worsen infection by promoting bacterial growth.
C. Provide education about pain management. While pain management education is important, the wound findings (purulent drainage, warmth, erythema) suggest possible infection, which requires medical intervention first.
D. Notify the provider about the findings. Signs of infection (erythema, warmth, purulent drainage) need to be reported immediately for further evaluation and treatment (e.g., wound culture, antibiotics).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ensure the patient is safe and leave to get them some water: The provider’s verbal statement is not an official order. The student nurse must ensure a written order is in place before implementing dietary changes.
B. Contact dietary to order the patient a full liquid meal: The student nurse cannot place orders. They must first verify that the provider has documented the order.
C. Request that the provider write the order in the chart: Orders must be documented in the patient’s medical record before they can be carried out. The student nurse should ensure the provider formally writes the order.
D. Record the information in the patient chart: The student nurse cannot chart an order that has not been officially written by the provider.
Correct Answer is A
Explanation
A. Placing an indwelling urinary catheter: Indwelling urinary catheters are a leading cause of catheter-associated urinary tract infections (CAUTIs), which are common healthcare-associated infections.
B. Administering medications through an NG tube: While NG tubes can introduce bacteria, they are not as high-risk as urinary catheters, which provide a direct route for infection.
C. Changing a sacral wound dressing: While wounds can become infected, proper wound care techniques minimize risk. Urinary catheters pose a greater risk due to prolonged exposure to bacteria.
D. Replacing an ostomy appliance: While maintaining hygiene is important, ostomy appliances are not a major source of healthcare-associated infections compared to urinary catheters.
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