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. A lesion of cranial nerve IX primarily affects swallowing and taste sensations rather than motor coordination or balance, so this is unlikely to explain the patient's symptoms.
B. Vestibular disease typically results in vertigo and balance issues, but the specific observations of slow alternating movements and loss of balance during the Romberg Test suggest a different underlying cause.
C. Dysfunction of the cerebellum would explain the patient's difficulties with rapid alternating movements and balance issues, as the cerebellum is responsible for coordinating motor activity and maintaining posture and balance. This aligns with the assessment findings, indicating a probable cerebellar dysfunction.
D. While an AVM in the frontal lobe could affect motor control, the specific symptoms presented, such as the inability to perform rapid movements and balance issues, are more characteristic of cerebellar dysfunction rather than a frontal lobe lesion.

A. Call a rapid response for more assistance B. Administer naloxone 0.4 mg SQ and reassess C. Check the temperature and apply warmed blankets D. Encourage the client to take deep breaths

Correct Answer is D

Explanation

A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.

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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?

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Correct Answer is C

Explanation

The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Correct Answer is D

Explanation

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