A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Document the client's history of skin allergies.

Photograph the lesion for the client's medical record.

Identify when the client first noticed the lesion.

Instruct the client on the use of daily sunscreen products.

Answer and Explanation

The Correct Answer is C

A.   Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B.   Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C.   Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D.   Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.

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Correct Answer is B

Explanation

A. Macule: A macule is a flat, discolored area of skin that is smaller than 1 centimeter in diameter and does not contain fluid.
B. Vesicle: A vesicle is a raised, fluid-filled lesion smaller than 1 centimeter in diameter.
Examples include blisters caused by conditions such as herpes simplex virus or contact dermatitis.
C. Papule: A papule is a raised, solid lesion smaller than 1 centimeter in diameter that does not contain fluid. Examples include pimples or insect bites.
D. Wheal: A wheal is a raised, red area of skin that is often accompanied by itching. It is typically caused by an allergic reaction and may have irregular borders.

A. Place the client in a private room. B. Administer intravenous vancomycin C. Wear a cover gown when caring for the client. D. Restrict fluid intake. E. Initiate supplemental oxygen.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Place the client in a private room.
- Essential: Placing the client in a private room helps prevent the spread of MRSA to other patients and reduces the risk of transmission.
Administer intravenous vancomycin.
- Essential: Vancomycin is an appropriate antibiotic choice for treating MRSA infections, and administering it intravenously allows for effective delivery of the medication to combat the infection.
Wear a cover gown when caring for the client.
- Essential: Wearing a cover gown provides an additional barrier of protection against potential contact with the client's infected wound and helps prevent transmission of MRSA to healthcare workers and other patients.
Restrict fluid intake.
- Contraindicated: Restricting fluid intake is not indicated in this scenario. Adequate hydration is essential for supporting the body's immune response and maintaining organ function, especially in the presence of fever and infection.
Initiate supplemental oxygen.
- Nonessential: Supplemental oxygen is not indicated based on the client's oxygen saturation of 96% on room air. Oxygen supplementation is typically reserved for clients who are hypoxic or experiencing respiratory distress, which is not the case here.

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A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

Which term should the nurse use to document a raised, fluid-filled lesion smaller than 1 centimeter?

Correct Answer is B

Explanation

A nurse is caring for a client. Exhibits For each potential nursing action, click to specify if the action is essential. nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

The nurse works in an office with a dermatologist. What equipment is most important to have readily available when a patient is undergoing skin testing for allergies?

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