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
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B. The client with leukemia may require monitoring, but the antiemetic is pre-emptive and not immediately critical.
C. The client with neutropenia and a possible infection poses the highest risk, as they are vulnerable to severe complications due to their compromised immune system. Immediate assessment is necessary to manage and treat potential infections promptly.
D. The breast cancer client scheduled for radiation requires care but is not in an urgent condition compared to the neutropenic patient.
Correct Answer is B
Explanation
A. Increasing fiber intake is generally beneficial for digestive health but alone may not address the client's specific concern regarding colon cancer risk, making this advice too narrow.
B. Discussing family history and early screening options with a primary care provider is crucial, as it can lead to earlier detection and intervention, especially given the family history of colon cancer.
C. The CEA blood test is not routinely used for cancer screening; it is primarily used to monitor treatment response or recurrence, not for predicting the development of cancer.
D. Waiting until the age of 60 to be concerned about colon cancer is not advisable, especially with a family history; proactive discussions about screening should begin earlier based on risk factors.