The nurse is changing the subclavian dressing of a client who is receiving total parenteral nutrition. When assessing the catheter insertion site, the nurse noticed the presence of a yellow drainage from around the sutures that are anchoring the catheter. Which actions should the nurse take first?
Administer a broad-spectrum antibiotic to prevent infection.
Notify the healthcare provider immediately and wait for further instructions.
Obtain a culture specimen of the drainage, apply a sterile dressing over the site, and monitor for any signs of infection.
Remove the sutures immediately to prevent further drainage.
The Correct Answer is C
A. Administering a broad-spectrum antibiotic is not the first action in this case. The first priority is to assess the situation and obtain a culture of the drainage to identify any infection before initiating antibiotics.
B. While notifying the healthcare provider is important, it is more important to take an initial action by obtaining a culture specimen. Waiting without taking action could delay appropriate care.
C. The best first action is to obtain a culture of the drainage to identify any potential infection, apply a sterile dressing, and continue to monitor the site for further signs of infection. Culturing the drainage helps guide the appropriate treatment.
D. Removing the sutures is not the appropriate action. The sutures should not be removed unless there is clear indication, as this could disrupt the integrity of the catheter placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administering a broad-spectrum antibiotic is not the first action in this case. The first priority is to assess the situation and obtain a culture of the drainage to identify any infection before initiating antibiotics.
B. While notifying the healthcare provider is important, it is more important to take an initial action by obtaining a culture specimen. Waiting without taking action could delay appropriate care.
C. The best first action is to obtain a culture of the drainage to identify any potential infection, apply a sterile dressing, and continue to monitor the site for further signs of infection. Culturing the drainage helps guide the appropriate treatment.
D. Removing the sutures is not the appropriate action. The sutures should not be removed unless there is clear indication, as this could disrupt the integrity of the catheter placement.
Correct Answer is B
Explanation
A. Epigastric discomfort is a common symptom of peptic ulcer disease, but it is not the priority finding. This symptom is usually manageable with appropriate treatment, such as antacids or proton pump inhibitors.
B. Hematemesis (vomiting blood) is a critical finding and indicates active bleeding, which can be life-threatening. This requires immediate attention as it suggests a potential complication, such as ulcer perforation or severe gastric bleeding, that can lead to hypovolemic shock. It is the priority finding because it indicates the need for urgent medical intervention.
C. Constipation is not a priority concern in a patient with peptic ulcer disease unless it is severe and related to medication (such as opioids). While it may be uncomfortable, it does not pose the immediate risk that hematemesis does.
D. Dyspepsia, or indigestion, is another common symptom of peptic ulcer disease. While it can be bothersome, it does not represent an acute, life-threatening issue like hematemesis does.
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