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 C
Explanation
A. While using the correct needle size is important for insulin administration, it is not the most critical aspect of discharge planning. The focus should be on managing blood glucose levels and recognizing when medical intervention is needed.
B. Monitoring the skin for dryness at the injection site is a good practice, but it is not the most urgent issue to address in discharge planning for a newly diagnosed diabetic client.
C. Consistently elevated blood glucose levels above 200 mg/dL may indicate poor control of diabetes and require prompt adjustments in treatment. Teaching the client to recognize and report hyperglycemia is essential to prevent complications such as diabetic ketoacidosis (DKA).
D. Eye exams are important for long-term diabetes management to monitor for diabetic retinopathy, but every 3 months is excessive. Annual eye exams are typically sufficient unless otherwise indicated by the healthcare provider.
Correct Answer is A
Explanation
A. A garden salad may contain raw vegetables, which can harbor bacteria and pose a risk of infection for a client with neutropenia, making this the concerning choice.
B. Applesauce is typically safe as it is a processed food that has been cooked, reducing the risk of bacterial contamination.
C. A baked potato is also safe as long as it is properly cooked and handled, which minimizes the risk of foodborne illness.
D. Steamed broccoli is safe because the cooking process eliminates harmful bacteria, making it a better choice for someone with neutropenia.