A client states that he has been experiencing oozing from his wound. What is the nurse's priority assessment for this client?
Culture the wound
Apply topical ointment to the wound
Inspect the wound and assess the drainage
Call the provider to initiate antibiotics
The Correct Answer is C
Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.
Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.
Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.
Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Determine whether it is temporary or permanent is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Determining whether the compromised immunity is temporary or permanent is an important assessment, but it should be done after ensuring the safety and infection prevention of the client. Compromised immunity can be temporary or permanent, depending on the cause, such as medication, disease, or genetic disorder.
Choice B reason: Take the client's vital signs every four hours is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Taking the client's vital signs every four hours is an important monitoring, but it should be done after ensuring the safety and infection prevention of the client. Vital signs can indicate the general health status and the presence of infection or inflammation, such as fever, tachycardia, or hypotension.
Choice C reason: Teach the family members to receive the flu shot annually is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Teaching the family members to receive the flu shot annually is an important education, but it should be done after ensuring the safety and infection prevention of the client. The flu shot is a vaccine that can protect the family members and the client from influenza, which can be a serious and potentially fatal infection for people with compromised immunity.
Choice D reason: Wash hands before entering the client's room is the nurse's priority action for a client with compromised immunity, because it is the most urgent and relevant. Washing hands before entering the client's room is a basic and essential infection prevention measure, which can protect the client from exposure to pathogens that can cause infection. People with compromised immunity have a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection.
Correct Answer is B
Explanation
Choice A reason: "I will use a humidifier during the winter months." is not the correct answer, because it indicates a good understanding of dry skin. Using a humidifier during the winter months is a helpful measure to prevent or treat dry skin, as it can increase the moisture level in the air, which can hydrate the skin and reduce the loss of natural oils.
Choice B reason: "I will shower every day in hot water." is the correct answer, because it indicates a need for further teaching about dry skin. Showering every day in hot water is a harmful practice that can worsen dry skin, as it can strip the skin of its natural oils, damage the skin barrier, and cause irritation and inflammation.
Choice C reason: "I will avoid tight belts." is not the correct answer, because it indicates a good understanding of dry skin. Avoiding tight belts is a helpful measure to prevent or treat dry skin, as it can reduce the friction and pressure on the skin, which can prevent skin breakdown and infection.
Choice D reason: "I will drink at least 3000 mL of water daily." is not the correct answer, because it indicates a good understanding of dry skin. Drinking at least 3000 mL of water daily is a helpful measure to prevent or treat dry skin, as it can hydrate the body and the skin, and flush out toxins and waste products.
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