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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Endogenous Infection: Endogenous infections originate from the client's own microbiota and typically do not involve medical interventions such as urinary catheterization.
B. Systemic Infection: Systemic infections affect the entire body and may not necessarily be related to the urinary tract.
C. Exogenous Infection: Exogenous infections originate from sources outside the client's body.
While the urinary tract infection could be caused by bacteria from the environment, it is more specifically categorized as a healthcare-associated infection (HAI) due to the indwelling urinary catheter being a risk factor.
D. Health Care-Associated Infection: A healthcare-associated infection (HAI) occurs as a result of healthcare interventions and can include infections related to urinary catheterization, surgery, or other medical procedures.
Correct Answer is B
Explanation
A. Implement neutropenia isolation: Neutropenia isolation is not applicable for a client with C. diff infection. Neutropenia isolation is used for clients with low neutrophil counts to protect them from exposure to pathogens due to their compromised immune system.
B. Disinfect equipment with bleach solution: Clostridium difficile spores are resistant to many disinfectants, but they can be effectively killed by bleach solutions (sodium hypochlorite).
Disinfecting equipment with bleach solution helps prevent the spread of C. diff infection.
C. Monitor the client for manifestations of fluid overload: Manifestations of fluid overload, such as edema or shortness of breath, are not typically associated with C. diff infection. Monitoring for fluid overload is important in other clinical contexts, such as heart failure.
D. Use alcohol hand sanitizer following client care: Alcohol-based hand sanitizers are not effective against C. diff spores. Hand hygiene should be performed with soap and water, as alcohol-based sanitizers are not effective against C. diff spores.
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