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.

Answer and Explanation

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.

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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.

A. “I will always carry glucose tablets or gels to treat episodes of hypoglycemia.”. B. “I will take my medications first thing in the morning on an empty stomach.”. C. “I should drink 6 oz. of orange soda if I feel nervous, sweaty, and lightheaded.”. D. “These medications help with the release of insulin so I have to start taking shots.”.

Correct Answer is A

Explanation

Choice A rationale

Acarbose and repaglinide are medications used to manage blood glucose levels in people with type 2 diabetes. Acarbose slows the digestion of carbohydrates in the gut, which helps to prevent spikes in blood glucose after meals. Repaglinide stimulates the pancreas to release more insulin. Both of these medications can cause hypoglycemia, or low blood sugar.

Therefore, carrying glucose tablets or gels is a good practice because they can quickly raise blood sugar levels during an episode of hypoglycemia.

Choice B rationale

Taking these medications on an empty stomach is not recommended. Acarbose should be taken with the first bite of each main meal. Repaglinide should be taken within 30 minutes before meals. Therefore, this statement does not indicate effective teaching.

Choice C rationale

Drinking orange soda to treat symptoms of hypoglycemia is not the best choice. While orange soda can increase blood sugar levels, it also contains other ingredients, like caffeine, that are not beneficial for people with diabetes. Glucose tablets or gels are a better option because they provide a fast-acting source of glucose and are easy to dose.

Choice D rationale

This statement is incorrect. While repaglinide does stimulate the pancreas to release more insulin, it does not mean that the person has to start taking insulin shots. Acarbose works by slowing the digestion of carbohydrates in the gut, not by affecting insulin release. Therefore, this statement does not indicate effective teaching.

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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?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is educating a client who has been newly prescribed acarbose in addition to repaglinide for the treatment of Type 2 diabetes. Which statement made by the client indicates that the teaching has been effective?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?