The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

Request a prescription to culture the wound

Request a prescription for broad spectrum antibiotics

Assure the client this is normal in the healing process

Clean the wound with sterile normal saline

Answer and Explanation

The Correct Answer is A

A. Requesting a prescription to culture the wound is the priority action because the presence of redness, warmth, and serosanguinous drainage could indicate an infection that needs to be confirmed and treated appropriately.
B. While antibiotics may be necessary if an infection is confirmed, it is crucial to first determine the presence of infection through culturing the wound.
C. Assuring the client that these findings are normal may delay necessary intervention if an infection is present, which could worsen the client's condition.
D. Cleaning the wound with sterile normal saline may be appropriate as part of wound care, but it does not address the underlying concern of possible infection and would not be prioritized over obtaining a culture.

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Correct Answer is B

Explanation

A. Magnesium at 2.0 mEq/L is within the normal range (1.6-2.2 mg/dL) and does not require immediate intervention.
B. A serum sodium level of 126 mEq/L indicates hyponatremia, which can lead to neurological complications, particularly in patients with brain cancer. Immediate reporting is necessary to manage potential risks such as seizures or altered mental status.
C. A potassium level of 3.5 mEq/L is on the lower limit of normal (3.5-5.3 mEq/L) but is still considered acceptable and does not require urgent action.
D. Calcium at 10 mg/L is an incorrect unit for this context, as total serum calcium is typically measured in mg/dL, and 10 mg/dL falls within the normal range (8.2-10.2 mg/dL).

A. Slow the rate of infusion B. Apply a warm compress to the site C. Discontinue the infusion D. Check for blood return

Correct Answer is C

Explanation

A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.

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Electrolyte	Normal Value Range
Serum sodium	135-145 mEq/L
Serum chloride	97-107 mEq/L
Serum potassium	3.5-5:3 mEq/L
Serum magnesium	1.6-2.2 mg/dL
Total serum calcium	8.2-10.2 mg/dL
lonized calcium	4.6-5.3 mg/dL
Serum phosphorus	2.5-4.5 mg/dL
Serum osmolality	275-295 mOsm/kg
Urine osmolality	250-900 mOsm/kg

The nurse is assessing a client who had a surgical excision of a basal cell carcinoma one week ago. Assessment findings include redness, warmth, and serosanguinous drainage from the site. What would be the priority action by the nurse?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client, who is receiving intravenous chemotherapy into a peripheral vein, says that the arm burns terribly in and around the intravenous site. What is the nurse's best first action?

Correct Answer is C

Explanation

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