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. A soft, low sofa can make it difficult for the client to rise and sit safely after surgery, which may risk hip dislocation.
B. A dining room chair with armrests provides support for the client to help them sit down and stand up safely, making this the most appropriate choice.
C. A canvas lawn chair typically does not provide adequate support or height, which can complicate the sitting and standing process post-surgery.
D. A desk type, swivel chair may not be stable or supportive enough for the client, increasing the risk of falls or injury after the hip replacement.
Correct Answer is B
Explanation
A. Picking up the implant with gloved hands does not ensure safety and proper handling of a radioactive material, as gloves do not provide adequate protection against radiation exposure.
B. Using long-handled forceps to pick up the implant and placing it in a lead container is the correct action, as it minimizes radiation exposure to the nurse and ensures the safe containment of the radioactive source.
C. Calling for the rapid response team is unnecessary in this scenario; the situation requires immediate containment of the radioactive material rather than emergency medical intervention.
D. Calling the radiation oncologist is not the first action; while it is important to inform the physician afterward, the priority is to secure the radioactive implant properly to prevent exposure.