Difficulty: Medium
Average Score: 64%
Simulated
Passage / Scenario
A client reporting redness, warmth, and swelling after stepping on a nail one week ago.A client arrives reporting redness, warmth, and swelling after stepping on a nail one week ago. What is the nurse's priority action?
Correct answer
D
Rationale
The correct answer is D: Request an X-Ray. This is the priority action because the client is presenting with redness, warmth, and swelling after stepping on a nail, which could indicate an infection or foreign body retained in the wound. An X-Ray is needed to assess for any foreign object or potential bone involvement. Cleansing the wound or dressing it can wait until further assessment is done. Identifying immunization history is not the priority in this situation.