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 D
Explanation
A. Gabapentin is an anticonvulsant commonly used to treat neuropathic pain, including trigeminal neuralgia. It works by stabilizing nerve activity and is appropriate for this condition.
B. Carbamazepine is considered the first-line treatment for trigeminal neuralgia as it decreases nerve impulses, which helps reduce pain. It is a commonly prescribed medication for this condition.
C. Baclofen is a muscle relaxant and can be used in combination with anticonvulsants to treat trigeminal neuralgia by reducing muscle spasms associated with nerve irritation.
D. Oxycodone is an opioid analgesic that treats general pain but is not typically effective for the specific type of neuropathic pain experienced in trigeminal neuralgia. Opioids do not address the underlying nerve activity and are not recommended for long-term management of this condition.
Correct Answer is B
Explanation
A. Washing the skin with water is generally acceptable, but applying scented lotion is not recommended as it may irritate the skin or interfere with treatment; only specific products as advised by the healthcare provider should be used.
B. Skin treatment markings are important for ensuring correct targeting of radiation during therapy and should remain intact for the duration of treatment to avoid misalignment.
C. While some precautions may be necessary, limiting time with others at home is not typically a requirement for external radiation, as it does not make the client radioactive.
D. Skin damage can occur from radiation treatment, and any changes should be reported to the healthcare provider, as monitoring and managing side effects is important for the patient's overall care.