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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Intermittent flatus and minor abdominal discomfort are not signs that would prompt the nurse to call the provider immediately. They are common and expected after surgery and anesthesia. They indicate that the client's bowel function is returning to normal.

Choice B reason: A minor headache and taking an overthe counter pain pill at home are not signs that would prompt the nurse to call the provider immediately. They are mild and manageable symptoms that may be related to stress, dehydration, or caffeine withdrawal. They do not indicate a serious complication or adverse reaction.

Choice C reason: Refusing pain medication and doing physical therapy are not signs that would prompt the nurse to call the provider immediately. They are indicators of the client's preference and motivation to recover. They may also suggest that the client's pain is wellcontrolled or tolerable.

Choice D reason: Paresthesia in the fingers and intense increasing pain in the shoulder are signs that would prompt the nurse to call the provider immediately. They are indicators of a possible nerve injury, compression, or ischemia that may result from the surgery, swelling, or hematoma. They may also indicate a worsening of the client's rheumatoid arthritis or a development of a complex regional pain syndrome. They require prompt assessment and intervention to prevent permanent damage or disability.

A. The client instills the prescribed number of eye drops into the conjunctival sac. B. The client washes her hands before instilling the eye drops. C. The client sets the cap to the eye drop container down in a manner that does not contaminate it. D. The client touches the administration dropper to the eye.

Correct Answer is D

Explanation

Choice A reason: The client instills the prescribed number of eye drops into the conjunctival sac is a correct action, because it ensures that the medication reaches the eye surface and does not spill out. The conjunctival sac is the space between the eyelid and the eyeball.

Choice B reason: The client washes her hands before instilling the eye drops is a correct action, because it prevents the introduction of microorganisms or foreign substances into the eye. Hand hygiene is an essential infection control measure.

Choice C reason: The client sets the cap to the eye drop container down in a manner that does not contaminate it is a correct action, because it preserves the sterility of the eye drop solution and prevents crosscontamination. The cap should be placed on a clean surface with the inner side facing up.

Choice D reason: The client touches the administration dropper to the eye is an incorrect action, because it can cause injury, infection, or contamination of the eye drop solution. The administration dropper should be held close to the eye, but not touch it.

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A client states that he has been experiencing oozing from his wound. What is the nurse's priority assessment for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with rheumatoid arthritis one day after shoulder surgery. What would prompt the nurse to call the provider immediately?

Correct Answer is D

Explanation

The nurse is providing education to a client regarding the administration of eye drops. Which of the following actions indicates the need for further client education?

Correct Answer is D

Explanation

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