Recent Nursing Test Question

[Murgy]

Yesterday I took at test where we had to put how we would take care of this patient who was diabetic with a surgical wound with pus-type discharge on bandage and had a temperature of 104 degrees. The following information was given and we had to put the following list in sequence order as to what intervention we would do first, second, third and fourth. What I want to know is what sequence would you list the following interventions?

a. acetaminophen (Tylenol)

b. IV antibiotics

c. wound care

d. sponge to wipe body with cool water

I'm interested in finding out, especially from RNs, what sequence you think is the correct sequence and why?

Sincerely, Murgy

[snoopy29]

First thing I would do is check patients blood sugar - if they are septic then it is likely to be climbing and DKA trumps an infection :)

[kathy313]

I'm not an RN, but anyways....acetaminophen first (start bringing fever down and for general discomfort). IV atb next, then provide the wound care. As for the cool water, I'd do that last if at all....don't want to give the pt. the chills....maybe warm water or cool cloth for their head or nape.

[aubreysmommy]

I would say Tylenol, sponge, wound care and then ATB. I hated questions like this. Since you will have to have an order for the ATB then you might as well do the things that you (as a nurse) can do first.

[morte, LPN, LVN]

either awful or devious question

[aubreysmommy]

While I do not think the sponging the pt down is something I would actually do....it is an option for a reason. In those types of questions they want you to do what you can as a nurse first. Since you can not order ATB...that could very well be last. The bad thing about nursing tests is that you can ALMOST ALWAYS spin it several different ways!!

Amanda RN

[lala_rn09]

i remember in school the instructors always telling me if it was on the exam then i had an order for it. I would almost say ABX, tylenol, wound care, sponge. ABX will help with the infection which can be a source of the fever, but you still need to get the fever down with the tylenol. wound care now that we have anx on board, and sponge last...

[SanFranSRNA]

IV antibiotic....Give IV antibiotic asap

Tylenol....trying to control the temperature

Cool bath.....Once again trying to lower the temperature

Wound Care.....I left this one last because I don't think that pus draining from the wound would kill anyone immediately.

This is not a fair question because it doesn't test on the implementation of ABC.

It would be fair if the question address the correct process of dealing with this type of patient. For example. A. Give antibiotic

B. Notify MD of temp 104

C. Cooling measures...ice packs, tylenol, fan.

D. Draw blood cultures after obtaining an order

Then I would do... B, D, A and C

[kathy313]

In reality, it's probably more like:Check the chart....make sure there's an order for the tylenol....call the doc while you hang onto the chart....no atb ordered either, wait for the doc to call you back. Go ahead and clean the wound while waiting, cool cloth (fever), doc finally calls back, gives you the order for the tylenol and an atb, then wait for pharmacy to send it!

[PopeJane3rd]

not a nurse but b, c, d, a

[snoopy29]

This is why I always failed tests because I would have to put none of the above!!! 0 marks for me but if they were really my patient my answers would be....

a) check BP and pulse and correct any shock

b) check blood sugar and correct hyper or hypoglycaemia secondary to sepsis.

c) Take blood cultures

d) Rule out any other source of infection - is there a post-op pneumonia or as the patient is diabetic an UTI???

and then and only then would I start IV abx but even then would run them at the same time as the anti-pyretics!!!!

It's one of those textbook questions that doesn't really reflect the reality of nursing. :)

[mommybess, BSN, RN]

If answering this for a nursing exam here is how I'd place these in order. Remember with nursing exams you always have an order for the options given and remember Maslow's Heirarchy.

Tylenol - fever needs to be treated asap. An increased temp and draining wound in a diabetic increases the risk of dehydration which increases the risk of DKA. As well as many other issues related to fluid imbalance and electrolyte imbalance.

Start Abx - we must assume that a dose is due

Wound care - pus draining wound - you would want this area free of drainage before applying a cool bath and you need to assess the wound for changes and a draining wound increases the risk of skin breakdown in diabetic.

Cool bath -but with 104 temp it would be more like not too cool bath

In the real world:

What is pt's LOC like? Full assessment for any other changes. Is there a foley? is it draining? (kidney fuction impared?) Medicate pt with Tylenol, culture wound, order labs if it is protocol in hospital, get accucheck for sugar levels - and give insulin if needed, run LR IV fluids to replace fluid loss through fever and draining wound, start IV abx if due, apply cool wash clothes to areas of warmth (arm pits, groin, forehead to help cool pt). Call MD with findings and for further orders.