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.

Answer and Explanation

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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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

Rationale:

Hypoxia: The client's decreased oxygen saturation (SaO2) despite oxygen therapy and the presence of respiratory distress (tachypnea, shortness of breath) indicate hypoxia.

Pneumonia: The client's fever, increased respiratory rate, decreased oxygen saturation, and crackles in the lungs are indicative of pneumonia, particularly in the right lower lobe as evidenced by the chest X-ray.

A. Apply petroleum jelly to the nares as needed to soothe mucous membranes. B. Attach a humidifier bottle to the base of the flow meter. C. Remove the nasal cannula while the client eats. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is B

Explanation

A. Petroleum jelly should not be used on the nares with oxygen therapy, as it is flammable and could pose a fire hazard. Non-petroleum-based lubricants should be used if needed.
B. A humidifier should be attached to the flow meter when delivering oxygen at higher flow rates (such as 6 L/min) to prevent dryness and irritation of the mucous membranes in the nose and throat.
C. The nasal cannula should generally be kept on during meals to ensure continued oxygen therapy, unless it is uncomfortable or the client has other medical needs.
D. The oxygen tubing should be secured to the client’s body or clothing in a way that does not restrict movement or cause injury, but securing it to the bed sheet could lead to a potential tripping hazard or interfere with mobility.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client has manifestations of dropdownanddropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 6 L/min via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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