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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sleeping on the stomach is not recommended for patients with GERD because it can increase pressure on the stomach, promoting acid reflux.
B. Lying on the right side can actually worsen GERD symptoms because it allows acid to flow more easily into the esophagus from the stomach, due to the positioning of the stomach and esophagus.
C. Sleeping on the back with the head flat does not provide sufficient elevation to prevent acid reflux, which can lead to symptoms worsening during the night.
D. Sleeping on the left side helps reduce the likelihood of acid reflux. This position prevents the stomach's contents from moving up into the esophagus, making it the most effective sleeping position for GERD.
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.
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