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 D
Explanation
Step 1 is to understand the therapeutic range for aPTT when a patient is on heparin therapy. The therapeutic range for aPTT is 1.5 to 2.5 times the normal value. Given that the normal aPTT value is around 30-40 seconds, the therapeutic range would be approximately 45-100 seconds. Therefore, an aPTT value of 75 seconds falls within this therapeutic range, indicating that the heparin therapy is effective.
Correct Answer is A
Explanation
Choice A rationale
Deep vein thrombosis (DVT) is a condition characterized by the formation of a blood clot in a deep vein, usually in the leg. One of the most common symptoms of DVT is swelling of the affected extremity. This occurs because the blood clot obstructs the flow of blood, causing fluid to build up in the tissues.
Choice B rationale
While redness can be a symptom of DVT, it is not typically confined to a small area. Instead, redness associated with DVT is usually more widespread and is often accompanied by other symptoms such as swelling and pain.
Choice C rationale
A cool, mottled extremity is not a typical symptom of DVT34. DVT usually causes the affected area to feel warmer than the surrounding areas due to inflammation caused by the blood clot.
Choice D rationale
The presence of bilateral peripheral pulses is not a specific finding for DVT34. In fact, the presence of strong peripheral pulses may suggest that blood flow is not significantly obstructed.
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