# Stage 5 — Take action. Place the five action clusters in the safest sequence for the initial response. Some actions may overlap in practice. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=373406&lang=en > language: en > subject: System-Specific Assessments > category: ROR ## Question Stage 5 — Take action. Place the five action clusters in the safest sequence for the initial response. Some actions may overlap in practice. After specimens when feasible, administer ordered empiric therapy matched to severity, colorectal operative site, MRSA risk, allergies, and local data; manage glucose by inpatient protocol and monitor for hypoglycemia. Perform a focused wound and systemic assessment, mark the erythema, screen for sepsis and deep or organ-space complication, notify surgery, and select precautions according to drainage containment. Support prompt opening and drainage as ordered and obtain an aseptic wound specimen; consider blood cultures when systemic assessment or bacteremia risk indicates them, without delaying urgent treatment if unstable. Document findings, notifications, precautions, specimens, source control, antimicrobial timing and reassessment, glycemic response, surveillance referral, wound teaching, follow-up, and accountable handoff. Reassess vital signs, perfusion, pain, erythema, drainage, glucose, laboratory trends, imaging, and culture results; refine antimicrobials and carry out the ordered wound-care and education plan. ## Explanation Safest sequence: 2 → 3 → 4 → 5 → 1 Assess severity, infection depth, drainage containment, and notify surgery first (choice 2). Obtain source control and the best available specimen, with blood cultures based on indication (choice 3). Give site- and severity-directed therapy after specimens when feasible, but never delay urgent treatment for instability; manage glucose safely (choice 4). Reassess and refine the plan as results arrive (choice 5). Complete documentation and accountable handoff last (choice 1), recognizing that documentation occurs throughout. ## In-depth explanation 1 — Define urgency and containment The first assessment determines whether the client is stable, whether deeper infection is plausible, and whether Standard or Contact Precautions apply. 2 — Control the source and preserve useful microbiology Opening and draining the incision is central. Obtain an aseptic wound specimen during the procedure; select blood cultures from the systemic assessment rather than by rote. 3 — Treat the likely organisms safely Colorectal-site empiric therapy considers gram-negative and anaerobic organisms and adds MRSA activity when risk indicates it. Glucose management follows inpatient orders and avoids hypoglycemia. 4 and 5 — Close the loop Trend the response, narrow therapy, apply surveillance criteria separately, teach wound care, and document decisions and owners. ## Clinical scenario Scenario (Stage 5 — Take action) The surgical team is responding at the bedside, and the nurse coordinates assessment, containment, source control, treatment, and reassessment. ## Key concepts - **Specimen during source control** — An aseptic specimen collected from the opened or drained infected site, improving relevance compared with a casual swab of surface material. - **Do not delay unstable care** — Obtain indicated cultures before antimicrobials when feasible, while recognizing that diagnostic sampling must not postpone urgent resuscitation and therapy in deterioration. - **Closed-loop reassessment** — Repeat the wound, systemic, glucose, laboratory, microbiology, and imaging assessment and explicitly change the plan when new data support escalation or narrowing. ## Related questions - [A nurse on a medical-surgical unit reviews the morning labs for a 67-year-old male client …](https://mymerci.kr/pages/nclex_q.php?qn_id=361711&lang=en) - [A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following ton…](https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=en) - [A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit…](https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=en) - [A 72-year-old male client is receiving a continuous IV heparin infusion for a left lower-e…](https://mymerci.kr/pages/nclex_q.php?qn_id=362064&lang=en) - [A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. 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Twenty minutes afte…](https://mymerci.kr/pages/nclex_q.php?qn_id=364947&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=373406&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=373406&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=373406&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=373406&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=373406&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._