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 A
Explanation
Choice A rationale
Diabetes mellitus can lead to several chronic complications, including retinopathy, which can cause blindness. Regular eye exams are crucial for early detection and treatment of diabetic retinopathy. Therefore, scheduling and keeping appointments for annual eye exams is an important part of managing diabetes.
Choice B rationale
While adequate fluid intake is generally important for overall health, it is not specifically effective in preventing kidney damage in patients with diabetes mellitus. Kidney damage in diabetes, also known as diabetic nephropathy, is caused by high blood sugar levels over time, not by dehydration.
Choice C rationale
Regular checks of cardiac enzymes are not a standard part of diabetes management. Cardiac enzymes are typically checked in the context of suspected heart disease or a heart attack, not as a routine measure in diabetes care.
Choice D rationale
While regular foot care is important in diabetes to prevent complications such as foot ulcers and infections, podiatry exams every 3 months are not typically necessary unless the patient has a history of foot problems or a high risk of foot complications.
Correct Answer is C
No explanation
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