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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Explanation
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C. A personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, significantly increases the risk for developing colorectal cancer due to chronic inflammation and cellular changes in the colon.
D. Having a distant relative with colorectal cancer may increase risk, but the personal history of inflammatory bowel disease is a stronger risk factor warranting emphasis in teaching.
Correct Answer is A
Explanation
A. Continuing antiepileptic drugs is crucial in patients with brain tumors, as these medications help prevent seizure activity, which is a common complication associated with brain tumors and surgical procedures.
B. While pain control is important, the specific medications used for postoperative pain management are determined after surgery; patients should be informed about general pain management strategies rather than specific drug administration.
C. Aspirin, an anticoagulant, should typically be stopped before surgery to reduce the risk of bleeding complications; therefore, patients should not continue taking it unless specifically directed by their healthcare provider.
D. Patients are usually advised to discontinue alternative or complementary therapies before surgery due to potential interactions with anesthesia or surgical procedures, and it should be clarified with the healthcare provider before proceeding.