The nurse is caring for a patient who had an above-the-knee amputation (AKA) five days ago.
The nurse notices a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch. What is the priority nursing action in this situation?
Administer the prescribed antibiotic early.
Apply a sterile dressing to the area.
Report the finding to the care provider.
Obtain a culture of the incision.
The Correct Answer is C
Choice A rationale
Administering the prescribed antibiotic early might not be the most immediate action. While antibiotics can help treat an infection, it’s crucial to first confirm the presence of an infection before starting antibiotic therapy.
Choice B rationale
Applying a sterile dressing to the area is important, but it’s not the priority nursing action. Dressings help protect the wound from further contamination, but they do not address the underlying issue of a potential infection.
Choice C rationale
Reporting the finding to the care provider is the priority nursing action. The symptoms described - a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch - suggest a possible infection. Immediate reporting allows for prompt evaluation and treatment, which is crucial in preventing further complications.
Choice D rationale
Obtaining a culture of the incision might be necessary to identify the specific causative agent of the infection, but it’s not the priority action. It’s more important to first report the findings to the care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Activated Partial Thromboplastin Time (aPTT) of 25 is within the normal range (25-35 seconds) and is not directly related to deep vein thrombosis (DVT)89.
Choice B rationale
A D-dimer level of 500 ng/mL is elevated (normal range is typically less than 250 ng/mL), which can indicate the presence of a clot, such as in DVT8910.
Choice C rationale
Prothrombin Time (PT) of 14 seconds is within the normal range (11-13.5 seconds) and is not directly related to DVT89.
Choice D rationale
A platelet count of 148,000 uL is within the normal range (150,000-450,000 uL) and is not directly related to DVT89.
Correct Answer is B
Explanation
Choice A rationale
Fewer doses of insulin may not necessarily be required with frequent self-monitoring of blood glucose. The need for insulin is determined by blood glucose levels, not the frequency of monitoring.
Choice B rationale
Frequent self-monitoring of blood glucose assists in gaining control over glucose levels. It can immediately tell you the effects of food choices, physical activity, and medication on blood glucose control.
Choice C rationale
While good blood glucose control can help minimize other health problems, frequent self- monitoring of blood glucose does not directly minimize other health problems.
Choice D rationale
Frequent self-monitoring of blood glucose is not necessarily the most cost-efficient method for glucose control. The cost efficiency depends on various factors, including the cost of testing supplies and the frequency of testing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.