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 D

Explanation

A. Strictureplasty is a surgical procedure, not a non-surgical procedure. It is used to treat strictures by widening them, typically in the gastrointestinal tract.
B. Strictureplasty does not remove strictures but rather works to widen or repair the narrowed areas, allowing for improved passage through the affected part of the gastrointestinal tract.
C. Strictureplasty is not used to repair fractures in bones. It is specifically used in the gastrointestinal system to treat strictures.
D. Strictureplasty is commonly performed in the treatment of Crohn's disease, particularly in cases where the disease causes strictures in the intestines. It is a procedure that can help maintain the integrity of the intestine by widening narrowed areas without the need for resection.

A. A patient with a scheduled physical therapy session in 1 hour. B. A patient with a routine follow-up appointment for a non-urgent condition. C. A patient with altered mental status and confusion. D. A patient with moderate pleuritis and requesting pain medication.

Correct Answer is C

Explanation

A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements about strictureplasty is correct?

Correct Answer is D

Explanation

Which patient should the nurse assess first after receiving a change-of-shift report?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching?

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?

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

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