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.
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Correct Answer is B
Explanation
A. While a diet of soft foods and liquid protein may be beneficial for a client undergoing chemotherapy, it is not the most critical intervention related to thrombocytopenia. Nutritional needs can be managed but do not address the immediate risk of bleeding or injury.
B. Teaching safety in the home to reduce injury and falls is the most important intervention. Clients with thrombocytopenia have a significantly increased risk of bleeding and bruising, making it essential to prevent falls and injuries that could lead to serious complications.
C. Spacing activities throughout the day can help manage fatigue, but it is not as urgent as ensuring the client is safe from injuries related to low platelet counts.
D. Frequent hand hygiene is important to prevent infections, especially in immunocompromised patients, but it does not directly address the primary concern of preventing injuries related to thrombocytopenia.
Correct Answer is A
Explanation
A. Continuing antiepileptic drugs is crucial in patients with brain tumors, as these medications help prevent seizure activity, which is a common complication associated with brain tumors and surgical procedures.
B. While pain control is important, the specific medications used for postoperative pain management are determined after surgery; patients should be informed about general pain management strategies rather than specific drug administration.
C. Aspirin, an anticoagulant, should typically be stopped before surgery to reduce the risk of bleeding complications; therefore, patients should not continue taking it unless specifically directed by their healthcare provider.
D. Patients are usually advised to discontinue alternative or complementary therapies before surgery due to potential interactions with anesthesia or surgical procedures, and it should be clarified with the healthcare provider before proceeding.