A nurse is conducting an assessment of a patient with a skin infection. Which assessment findings should the nurse prioritize when planning care for this patient?
The patient's ability to ambulate independently.
The size, shape, and characteristics of any skin lesions or blisters.
The patient's response to pain management interventions.
The patient's daily fluid intake.
The Correct Answer is B
Choice A rationale:
"The patient's ability to ambulate independently." While ambulation is an important aspect of patient care, in the context of a skin infection, the priority should be assessing and managing the infection and associated symptoms.
The patient's ability to ambulate independently should be considered but may not be the highest priority.
Choice B rationale:
"The size, shape, and characteristics of any skin lesions or blisters." This is the correct answer.
When assessing a patient with a skin infection, it is essential to prioritize the evaluation of the affected area's skin lesions or blisters.
This assessment can help determine the severity of the infection, whether there are signs of abscess formation, and guide appropriate treatment.
Choice C rationale:
"The patient's response to pain management interventions." While pain management is important, it is a secondary consideration in the context of a skin infection.
Addressing the infection's source and associated complications, such as abscesses, should take precedence.
Choice D rationale:
"The patient's daily fluid intake." While monitoring fluid intake is generally important in patient care, it may not be the highest priority in assessing and managing a skin infection unless there are specific concerns related to hydration status.
The primary focus should be on the infection itself and its associated symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Administering prescribed antibiotics is a crucial nursing intervention in managing cellulitis.
Antibiotics are the primary treatment for bacterial infections, and they are necessary to eradicate the infection.
Choice B rationale:
Teaching the patient proper wound care and hygiene is essential for managing cellulitis.
Proper wound care can help prevent the infection from worsening and promote healing.
Education on wound care is a vital aspect of nursing care for cellulitis.
Choice C rationale:
Advising the patient to apply cold compresses to the affected area is not typically recommended in the management of cellulitis.
Cold compresses may provide some relief for discomfort, but they are not a primary treatment for cellulitis.
Antibiotics and wound care are the mainstay of treatment.
Choice D rationale:
Advising the patient to limit fluid intake is not a standard nursing intervention for managing cellulitis.
In fact, it's important for patients with cellulitis to stay well-hydrated to support their overall health and immune function.
Choice E rationale:
Monitoring for signs of complications, such as fever or worsening symptoms, is a crucial nursing intervention in managing cellulitis.
Cellulitis can lead to serious complications if not promptly identified and treated.
Close monitoring allows for early intervention if complications arise.
Correct Answer is B
Explanation
Choice A rationale:
Maintaining good hand hygiene is essential in preventing cellulitis and other infections.
Discouraging hand hygiene is not appropriate advice.
Proper handwashing can help reduce the risk of infection transmission.
Choice B rationale:
The nurse should advise the patient to promptly treat any cuts, wounds, or insect bites to prevent cellulitis.
This is a valid and important preventive measure.
Prompt wound care, including cleaning, disinfection, and covering wounds, can reduce the risk of infection.
Choice C rationale:
Sharing personal items with others is not a safe practice in preventing cellulitis.
Sharing items like towels, razors, or personal care items can increase the risk of bacterial transmission and infection.
The nurse should advise against sharing personal items.
Choice D rationale:
Avoiding a healthy lifestyle can impact an individual's overall health, including their immune system function, which can influence their risk of cellulitis.
However, it's not the primary focus of preventive measures for cellulitis.
The nurse should encourage a healthy lifestyle but also provide specific advice on wound care and hygiene to prevent cellulitis.
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