An older client has several small vesicles with eroded centers on the lips. What is the first action for the nurse to perform?

Question

1. Notify the healthcare provider of the lip vesicles.
2. Document the assessment findings in the medical record.
3. Teach the client to perform careful hand washing.
4. Review the client's temperatures and white blood cell count.

Answer 1

1. Notify the healthcare provider of the lip vesicles.

Explanation: 1. The nurse needs to obtain a prescription to treat what appears to be herpes simplex, otherwise known as a fever blister. Clusters of vesicles with eroded centers, ulcers on the lips, and mucosa can indicate the presence of herpes simplex or zoster.
2. The nurse will document the assessment findings last.
3. The client will need to be taught to wash their hands to avoid spreading the virus and to avoid a secondary infection. However, the risk of spread and infection is not great and this is not the priority action.
4. The client likely shows little to no signs of infection. Herpes simplex tends to be localized and not cause systemic symptoms of clinical significance.