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. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.
Correct Answer is D
Explanation
A. Cheddar cheese contains lactose and is not an ideal choice for a low-lactose diet, as it may cause discomfort in clients who are lactose intolerant.
B. Cottage cheese also contains lactose, though in smaller amounts than some other dairy products, but it is still not the best choice for someone on a low-lactose diet.
C. Low-fat yogurt may contain some lactose, but it also contains probiotics, which can help with digestion and may be tolerated better than other dairy products. However, for someone on a strict low-lactose diet, it may not be the best choice.
D. Soymilk is a non-dairy alternative and is typically lactose-free, making it the best choice for someone on a low-lactose diet. It provides a dairy-free option for those needing to avoid lactose.
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