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 B
Explanation
Choice A Rationale: Keeping the diaphragm in place for at least 4 hours after intercourse is a recommendation, but it does not address the specific concern of the client wanting to continue using her diaphragm postpartum.
Choice B Rationale: Having the client's provider refit her for a new diaphragm is the appropriate instruction after childbirth. The size and shape of the cervix can change postpartum, affecting the fit of the diaphragm.
Choice C Rationale: Using an oil-based vaginal lubricant can damage the diaphragm and is not recommended.
Choice D Rationale: Storing the diaphragm in sterile water after each use is not a standard practice. Proper cleaning and storage in a dry, cool place are recommended.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Rationale: Forgetting names and faces, especially when previously introduced, can be a sign of memory impairment, which is common in Alzheimer's disease. Choice B Rationale: Neglecting bills and financial responsibilities is a sign of impaired executive function, which can occur in Alzheimer's disease.
Choice C Rationale: Mentioning excitement about starting a new job after retirement is a typical sign of Alzheimer's disease.
Choice D Rationale: Repeatedly forgetting that one has already read the newspaper and reading it again can be a sign of short-term memory loss, a characteristic of Alzheimer's disease.
Choice E Rationale: Placing car keys in unusual places and misplacing items like shoes in unexpected locations can be signs of disorientation and memory problems, which are common in Alzheimer's disease.
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