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 B

Explanation

A. Fever and chills are often indicative of infection, which may be a concern with TPN, but they are not typically the immediate concern if the TPN solution is not infusing.
B. Shakiness and diaphoresis (sweating) can occur due to hypoglycemia, which is a potential consequence of an interrupted TPN infusion. TPN provides glucose to the client, and a disruption in the infusion could cause a drop in blood sugar, leading to shakiness and diaphoresis.
C. Excessive thirst and urination are common symptoms of hyperglycemia or diabetes, but they are not typically seen with an interrupted TPN infusion.
D. Hypertension and crackles are more related to fluid overload or heart failure, which would not be an immediate concern in the case of an infusion pump malfunction for TPN.

A. Plan for periods of rest during activities, Monitoring the client's oxygen saturation B. Place the client on strict fluid restriction C. Placing the client on oxygen D. Restrict the client's smoking to 5 cigarettes per day

Correct Answer is ["A","C"]

Explanation

A. Planning for periods of rest during activities and monitoring the client's oxygen saturation are essential interventions for a client with pneumonia. Rest helps conserve energy and reduces the workload on the respiratory system, while monitoring oxygen saturation ensures that the client is maintaining adequate oxygen levels, which is crucial in pneumonia.
B. Placing the client on strict fluid restriction is not appropriate for pneumonia. In fact, adequate hydration is important to help thin respiratory secretions and facilitate expectoration.
C. Placing the client on oxygen is often necessary for clients with pneumonia, especially if they are hypoxic or have difficulty maintaining adequate oxygen levels. Supplemental oxygen supports the respiratory system and improves oxygenation.
D. Restricting the client's smoking to 5 cigarettes per day is not an appropriate intervention. Smoking should be completely stopped to help reduce the risk of further respiratory complications. Smoking cessation is a priority in managing respiratory conditions like pneumonia

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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

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?

Correct Answer is B

Explanation

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Correct Answer is ["A","C"]

Explanation

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