The nurse is giving discharge instructions to a client newly diagnosed with lung cancer. The nurse understands the client requires additional discharge teaching when the client states:
"I will really try to quit smoking so I will use the Nicorette gum to help."
"We will contact the American Cancer Society to help my family and I cope with all of this."
"It's ok for other people to smoke in the house around me, so long as I don't smoke myself."
"My family and I will spend more time together doing things we like to do."
The Correct Answer is C
A. This statement indicates the client is aware of the importance of quitting smoking and is taking steps to do so, which is a positive action in managing their health after a lung cancer diagnosis.
B. Contacting the American Cancer Society shows the client and their family are seeking support, which is beneficial for coping with cancer, indicating good understanding of available resources.
C. Allowing others to smoke in the house poses significant health risks due to secondhand smoke exposure, which can aggravate the client's condition and hinder recovery. This indicates a lack of understanding regarding the dangers of smoking and the need for a smoke-free environment.
D. Spending quality time with family is a positive coping mechanism and reflects the client’s recognition of the importance of emotional support during their treatment journey.
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Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.