Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Administer the prescribed antibiotic early.
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.
B. Apply a sterile dressing to the area.
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.
C. Report the finding to the care provider.
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.
D. Obtain a culture of the incision.
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.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nurs 200 Proctored Exam Roxoborouh Memorial College. Take the full exam now
Full Explanation
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.
Similar Questions
A patient is prescribed metronidazole orally.
What statement should be included in the discharge teaching?
A. Metronidazole may cause constipation.
While constipation can be a side effect of many medications, it is not commonly associated with metronidazole.
B. Metronidazole can cause anxiety.
Anxiety is not a common side effect of metronidazole. If a patient experiences anxiety while taking metronidazole, it’s important to discuss this with a healthcare provider as it may be related to other factors.
C. Metronidazole may cause an unusual metallic taste in your mouth.
Metronidazole may cause an unusual metallic taste in the mouth. This is a common side effect of the medication and is usually temporary. Patients should be advised that if the metallic taste persists or becomes bothersome, they should consult their healthcare provider.
D. Metronidazole will cause an upset stomach.
While metronidazole can cause gastrointestinal upset, it’s not guaranteed to cause an upset stomach in every patient. If a patient experiences persistent or severe gastrointestinal upset while taking metronidazole, they should consult their healthcare provider.
Full Explanation
Choice A rationale
While constipation can be a side effect of many medications, it is not commonly associated with metronidazole.
Choice B rationale
Anxiety is not a common side effect of metronidazole. If a patient experiences anxiety while taking metronidazole, it’s important to discuss this with a healthcare provider as it may be related to other factors.
Choice C rationale
Metronidazole may cause an unusual metallic taste in the mouth. This is a common side effect of the medication and is usually temporary. Patients should be advised that if the metallic taste persists or becomes bothersome, they should consult their healthcare provider.
Choice D rationale
While metronidazole can cause gastrointestinal upset, it’s not guaranteed to cause an upset stomach in every patient. If a patient experiences persistent or severe gastrointestinal upset while taking metronidazole, they should consult their healthcare provider.
A patient diagnosed with diabetes has severe peripheral neuropathy resulting in numbness and reduced sensation of the feet.
What intervention should the nurse teach the patient to prevent injury as a result of this complication?
A. Wear closed-toe shoes when walking.
Wearing closed-toe shoes when walking can help protect the feet from injuries. However, it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
B. Soak feet daily to remove pathogens.
Soaking feet daily to remove pathogens can help maintain hygiene, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
C. Examine your feet daily.
Examining your feet daily is a crucial intervention for patients with severe peripheral neuropathy. Due to the numbness and reduced sensation, patients might not notice injuries or changes in their feet. Regular self-examination can help detect any abnormalities early, preventing further complications.
D. Use lotion on all areas of the feet for moisture.
Using lotion on all areas of the feet for moisture can help prevent dryness and cracking of the skin, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Full Explanation
Wearing closed-toe shoes when walking can help protect the feet from injuries. However, it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice B rationale
Soaking feet daily to remove pathogens can help maintain hygiene, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
Choice C rationale
Examining your feet daily is a crucial intervention for patients with severe peripheral neuropathy. Due to the numbness and reduced sensation, patients might not notice injuries or changes in their feet. Regular self-examination can help detect any abnormalities early, preventing further complications.
Choice D rationale
Using lotion on all areas of the feet for moisture can help prevent dryness and cracking of the skin, but it does not directly address the issue of numbness and reduced sensation due to severe peripheral neuropathy.
The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?
A. “My feet look reddish when I put them down.”.
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
B. “I noticed that the hair on my feet and legs is gone.”.
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
C. “My legs were so cold I had to put a heating pad on them.”.
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
D. “My legs start to hurt when I walk to get my mail.”.
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow. However, this symptom does not require immediate intervention but should be evaluated further.
Full Explanation
Choice A rationale
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
Choice B rationale
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
Choice C rationale
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
Choice D rationale
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.
However, this symptom does not require immediate intervention but should be evaluated further.