A nurse is assessing a patient who presents with a scaly, crusted lesion with a central ulceration on the lower leg, as shown in the image. The lesion appears rough, firm, and does not heal despite previous treatments. The nurse suspects squamous cell carcinoma (SCC). What is the priority nursing action?

Apply an antibiotic ointment and reassess in two weeks.

Refer the patient to a dermatologist for a biopsy.

Reassure the patient that the lesion is benign and monitor for changes.

Educate the patient on proper wound care and sun protection.

Answer and Explanation

The Correct Answer is B

A. Apply an antibiotic ointment and reassess in two weeks. SCC is a form of skin cancer and requires biopsy for diagnosis. Simply applying an antibiotic and waiting could delay necessary treatment.

B. Refer the patient to a dermatologist for a biopsy. The priority action for a suspicious lesion that does not heal is to refer the patient for biopsy and further evaluation, as early detection and treatment of SCC are crucial.

C. Reassure the patient that the lesion is benign and monitor for changes. SCC can be aggressive if untreated, and assuming benignity without biopsy could result in delayed diagnosis and worsening prognosis.

D. Educate the patient on proper wound care and sun protection. While wound care and sun protection are important, the priority is obtaining a definitive diagnosis through biopsy.

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Correct Answer is D

Explanation

A. Medicate the client for pain: Pain management is essential after surgery; however, it is not the most critical action. Unrelieved pain could indicate a complication, such as compartment syndrome, which requires further assessment.

B. Direct the client to perform exercises of the ankle and toes: Performing ankle and toe exercises helps prevent complications such as venous thromboembolism (VTE) and promotes circulation, but it is not the priority over assessing for complications.

C. Instruct the client on the use of crutches: Teaching the client how to use crutches is important for mobility, but this is not the most immediate postoperative concern.

D. Perform neurovascular checks of the extremities: This is the most important intervention because neurovascular compromise (e.g., compartment syndrome) can occur after orthopedic surgery. Checking circulation, movement, and sensation (CMS) is critical for early detection of complications.

A. Have the nurse wear an N95 respirator during transport. B. Use a standard wheelchair with no additional precautions. C. Have the patient wear a surgical mask during transport. D. Place the patient in a negative-pressure isolation room during transport

Correct Answer is C

Explanation

A. Have the nurse wear an N95 respirator during transport. While the nurse should wear an N95 respirator when providing direct care to a patient with TB in a hospital room, the focus during transport is on preventing airborne transmission from the patient to others.

B. Use a standard wheelchair with no additional precautions. Standard precautions are not sufficient for airborne diseases like TB. Without proper precautions, the patient may spread Mycobacterium tuberculosis to others during transport.

C. Have the patient wear a surgical mask during transport. A surgical mask on the patient helps contain respiratory droplets and prevents the spread of TB during transport. This is the standard precaution for transporting patients with airborne infections.

D. Place the patient in a negative-pressure isolation room during transport. Negative-pressure isolation rooms are used for patients while they are in the hospital room, not during transport. Negative pressure cannot be maintained in an open environment.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Correct Answer is D

Explanation

A nurse is preparing to transport a patient with active tuberculosis (TB) to another department for a diagnostic procedure. Which of the following infection control precautions should the nurse implement?

Correct Answer is C

Explanation

A patient is diagnosed with gout and asks the nurse how to prevent future flare-ups. Which statement by the patient indicates a correct understanding of dietary modifications for gout management?

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

A nurse is providing teaching for a client who is postoperative following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for wound healing?

A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

A nurse is reviewing the medical record of a patient diagnosed with Stevens-Johnson Syndrome (SJS). Which of the following findings should the nurse identify as the most likely cause of this condition?

A nurse is performing a skin assessment on a patient and suspects basal cell carcinoma (BCC). Which of the following findings would support this suspicion?