RN Skill Care

The nurse in the surgical care center will be assisting the primary health care provider to perform a punch biopsy of a client's skin lesion that is suspicious for skin cancer. Which interventions would included in the preprocedure plan of care? Select all that apply

1 Obtain an informed consent.
2 Clean the area of the lesion with water.
3 Prepare to apply direct pressure to the biopsy site after the procedure.
4 Tell the client that a small piece of tissue will be removed for examination.
5. the client about the need to cleanse the site postprocedure with hydrogen peroxide and a topical corticosteroid every 4 hours.

Answer : 1,3,4

Rationale:
The nurse would obtain an informed consent from the client because the procedure is invasive. The nurse would cleanse the biopsy site with an antibacterial solution (not water) before the biopsy. The client is informed that a small piece of tissue will be removed for examination. Direct pressure is applied to the area to stop bleeding after the procedure. In the postprocedure period, the client is usually directed to keep the site clean and dry; antibiotic ointment may be prescribed, but normally a topical corticosteroid is not necessary.

Strategy:
Focus on the subject, care of the client undergoing punch biopsy. Recalling that informed consent is required for any invasive procedure will assist you in selecting option 1. Recall that a punch biopsy involves removal of a small piece of tissue; this will assist you in selecting option 4. Knowledge of general principles related to postprocedure care after biopsy will assist you in selecting option 3.

Test Tips: Remember this text.The MOST deadly conditions are typically the MOST tested conditions, since the main goal of nursing school
is to create safe nurses.

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