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. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.
Correct Answer is D
Explanation
A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.