A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?
A Cleanse the wound
B Identify when the client was immunized
C Dress the wound
D Request an X-Ray
The Correct Answer is D
Choice A Rationale: Cleansing the wound may be necessary, but the priority in this case is to assess for any retained foreign bodies, such as the nail, and potential structural damage, which can be done through an X-ray.
Choice B Rationale: The client's immunization history is not the priority when assessing and managing a wound like this.
Choice C Rationale: Dressing the wound may be necessary but should come after assessing for retained foreign bodies and potential structural damage.
Choice D Rationale: Requesting an X-ray is the priority action because it helps determine if the nail is still present and if there is any damage to deeper structures, such as bones or foreign body remnants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Correct Answer is D
Explanation
Choice A Rationale: Checking the patient's orientation to time and date is a part of assessing cognitive function but is not specific to the Mini-Cog exam.
Choice B Rationale: Obtaining a list of the patient's prescribed medications is important for the overall assessment but is not specific to the Mini-Cog exam.
Choice C Rationale: Determining the patient's ability to recognize a common object is not a component of the Mini-Cog exam.
Choice D Rationale: Asking the patient to draw a clock with a specific time is a key component of the Mini-Cog exam, which assesses cognitive impairment and is commonly used to screen for Alzheimer's disease.
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