Stage 4 — Generate solutions. Which actions appropriately address Mr. B's suspected colorectal incisional SSI? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Appropriate actions: 1, 2, 3, and 5 Perform a focused severity and depth assessment and notify surgery (choice 1). Select precautions from whether drainage is contained rather than applying Contact Precautions automatically (choice 2). Combine ordered source control with an aseptic wound specimen and indication-based blood cultures, without delaying urgent treatment in instability (choice 3). Select empiric treatment from severity, colorectal site, MRSA risk, allergies, and local data, then narrow promptly (choice 5). Cefepime alone lacks anaerobic coverage (choice 4). Prolonged prophylaxis and a glucose target below 80 mg/dL are unsafe and unsupported (choice 6).
Wrong — choice 4 Cefepime covers many gram-negative organisms but not anaerobes. A colorectal-site infection requires anaerobic consideration, so cefepime alone is not complete empiric coverage.
Wrong — choice 6 Antibiotics used to treat an established infection are not restarted prophylaxis, and prophylaxis is not continued for 30 days. CDC's perioperative SSI-prevention glucose target is below 200 mg/dL; forcing glucose below 80 mg/dL creates hypoglycemia risk.
Nuance Blood cultures are not mandatory for every superficial SSI. They are considered when systemic features or bacteremia risk make them useful. Likewise, Contact Precautions depend on whether wound drainage is major or uncontained.
Scenario (Stage 4 — Generate solutions)The client remains hemodynamically stable while the surgical team evaluates the incision and the nurse prepares immediate bedside actions.
Drainage-dependent precautions — Standard Precautions for minor or limited contained drainage, with Contact Precautions added for major or uncontained drainage until it stops or can be contained.
Indication-based blood cultures — Blood cultures selected from systemic severity, high fever, hypotension, bacteremia concern, or special risk rather than ordered automatically for every superficial wound infection.
Antimicrobial de-escalation — Stopping unnecessary agents or narrowing spectrum, route, and duration as source control, microbiology, infection depth, organ function, and clinical response become clear.