The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

Request a prescription to culture the wound

Request a prescription for broad spectrum antibiotics

Assure the client this is normal in the healing process

Clean the wound with sterile normal saline

Answer and Explanation

The Correct Answer is A

A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.

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Correct Answer is C

Explanation

A. Using a commercial medicine to remove a corn is not recommended, as it can cause skin damage and infection; diabetic clients should seek professional care for such issues.
B. Soaking feet daily in cool water can lead to skin maceration and should generally be avoided; it is better to wash and dry feet gently.
C. Utilizing a mirror to examine the soles of the feet indicates proper awareness and self-care, as diabetic clients need to monitor for any injuries or changes that could lead to complications.
D. Cutting nails in a concave manner is incorrect; nails should be cut straight across to prevent ingrown toenails.

A. Large cluster of pustules in the right axilla B. Raised, tubular, white areas on the arms C. Beige, small brown spots on the backs of both hands D. Irregular shaped, blue mole with white specks on lower leg

Correct Answer is D

Explanation

A. A large cluster of pustules may indicate an infection or inflammatory process, but it is not necessarily indicative of an immediate danger compared to other options.
B. Raised, tubular, white areas may represent benign conditions, such as skin tags or cysts, which generally do not require urgent evaluation unless symptomatic.
C. Beige, small brown spots are often benign, such as liver spots or freckles; these typically do not signal immediate concern unless there are changes in size or color.
D. An irregular shaped, blue mole with white specks raises significant concern for potential melanoma, a serious form of skin cancer; any atypical characteristics in moles warrant immediate evaluation to rule out malignancy.

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The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse teaches a diabetic client how to perform foot care. Which action by the client would indicate that they can correctly perform foot care?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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