A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Document the client's history of skin allergies.

Photograph the lesion for the client's medical record.

Identify when the client first noticed the lesion.

Instruct the client on the use of daily sunscreen products.

Answer and Explanation

The Correct Answer is C

A.   Document the client's history of skin allergies: While important for the client's overall care, documenting the history of skin allergies is not the priority when assessing a new skin lesion.
B.   Photograph the lesion for the client's medical record: Documenting the appearance of the lesion is important for the client's medical record, but it is not the priority when initially assessing the lesion.
C.   Identify when the client first noticed the lesion: The priority is to gather information about the onset and characteristics of the lesion to determine its potential severity and urgency of intervention.
D.   Instruct the client on the use of daily sunscreen products: While sun protection is important for skin health, it is not the priority when assessing a new skin lesion.

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Correct Answer is A

Explanation

A. Place all clients who have manifestations on contact precautions: Given the suspicion of Clostridium difficile infection due to the development of watery diarrhea in multiple clients, it is appropriate to place these clients on contact precautions until the diagnosis is confirmed or ruled out. Contact precautions help prevent the spread of the infection by requiring healthcare workers to wear gloves and gowns when entering the room.
B. Obtain stool cultures from all clients on the nursing unit: While obtaining stool cultures may be necessary to confirm the diagnosis of C. difficile infection, implementing contact precautions is more immediate and necessary to prevent transmission.
C. Request the providers to initiate antibiotic therapy for every client on the unit: Initiating antibiotic therapy for every client on the unit without confirmation of C. difficile infection is not appropriate and may contribute to antibiotic resistance.

D. Perform hand hygiene with an alcohol-based agent: Hand hygiene is essential in preventing the spread of infection, but in the case of C. difficile, handwashing with soap and water is recommended over alcohol-based hand sanitizers due to the spore-forming nature of the bacteria.

A. Administering analgesic medications B. Performing gentle massage on the affected area C. Applying a heating pad to the affected area D. Using topical antibiotics on the affected area

Correct Answer is A

Explanation

A. Administering analgesic medications: Analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, can help alleviate pain associated with impaired skin integrity by reducing inflammation and blocking pain signals.
B. Performing gentle massage on the affected area: While massage can sometimes provide relief for certain types of pain, it may not be appropriate for all types of impaired skin integrity and could potentially exacerbate the condition or cause further damage.
C. Applying a heating pad to the affected area: Heat therapy may be contraindicated for certain types of impaired skin integrity, as it can increase inflammation and worsen pain. It is not
typically recommended as a primary intervention for managing pain in this context.
D. Using topical antibiotics on the affected area: Topical antibiotics are used to treat or prevent infections but are not primarily indicated for pain management associated with impaired skin
integrity.

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A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse working on a medical-surgical unit suspects that several clients have Clostridium Difficile (C-Diff) when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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