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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.
Correct Answer is C
Explanation
A. Reading glasses do not offer sufficient protection against the light sensitivity that results from photodynamic therapy. Special protective eyewear is needed to protect the eyes from exposure to bright light during recovery.
B. Clients are usually instructed to fast before treatments that involve anesthesia or sedation, such as photodynamic therapy. Eating a full breakfast is not typically recommended before this type of treatment.
C. After photodynamic therapy, clients become extremely sensitive to light, including sunlight. Exposure to sunlight or strong indoor lights can cause skin damage, so clients are advised to avoid sun exposure for at least 6 weeks.
D. Skin markings made for treatment guidance should be preserved between treatments, but this is less critical in photodynamic therapy compared to radiation therapy, where precise location is essential for targeting tumors.
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