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 C
Explanation
Choice A rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hypoglycemia.
Choice B rationale
Insulin resistance is a characteristic of type 2 diabetes, not type 1 diabetes. The client’s blood glucose levels are well controlled, which suggests that the client’s insulin regimen is effective, not that the client is demonstrating signs of insulin resistance.
Choice C rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is demonstrating good control of blood glucose.
Choice D rationale
The client’s fasting blood glucose level, postprandial blood glucose level, and hemoglobin A1c level are all within the target range for good blood glucose control in diabetes. Therefore, the client is not at an increased risk for developing hyperglycemia.
Correct Answer is A
Explanation
Choice A rationale
The client diagnosed with peripheral arterial disease has impaired tissue integrity related to ischemic tissue of the legs and feet. This condition is often caused by factors such as physical trauma, thermal factors, chemical injury, infection, nutritional imbalances, fluid imbalances, and altered circulation. The most appropriate outcome to include in the care plan would be for the client to verbalize an understanding of appropriate foot care measures by discharge. This is because maintaining skin integrity and providing effective wound care are crucial aspects of managing this condition. By understanding and implementing appropriate foot care measures, the client can help prevent further tissue damage, promote healing, and improve their overall quality of life.
Choice B rationale
While taking anti-platelet medications can be an important part of managing peripheral arterial disease, it may not directly address the nursing problem of impaired tissue integrity. Anti-platelet medications can help prevent blood clots and improve blood flow, but they do not directly promote wound healing or tissue regeneration.
Choice C rationale
Discussing exercises that promote healing of wounds can be beneficial for the client. However, it’s important to note that exercises should be appropriate for the client’s condition and overall health status. Overexertion or inappropriate exercises could potentially exacerbate the condition and further impair tissue integrity.
Choice D rationale
Recognizing the need for an amputation in the near future can be a realistic outcome for some clients with severe peripheral arterial disease. However, this is typically considered a last resort when all other treatment options have failed. It’s also a drastic measure that can significantly impact the client’s quality of life.
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