165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)
Assess the appearance of the wound
Place the swab in the culture tube
Cleanse the wound with 0.9% sodium chloride
Cover the wound with a sterile dressing
Obtain the specimen from granulation tissue of the wound
The Correct Answer is A,C,E,B,D
A. Assess the appearance of the wound first to determine its condition and document characteristics such as drainage, size, and tissue type before collecting the specimen.
B. Place the swab in the culture tube immediately after obtaining the specimen to prevent contamination and preserve the sample.
C. Cleanse the wound with 0.9% sodium chloride to remove surface contaminants, which helps ensure the culture reflects true pathogens within the wound bed.
D. Cover the wound with a sterile dressing to protect the area from external contamination and promote healing after the specimen has been collected.
E. Obtain the specimen from granulation tissue of the wound, avoiding pooled drainage or necrotic areas, to ensure the most accurate culture results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ham sandwich with milk: Ham is pork, which is prohibited in kosher dietary laws. Additionally, mixing meat and dairy in the same meal is not allowed in kosher practice.
B. Scrambled eggs and toast with milk: Eggs, bread, and milk are all considered kosher when prepared properly, and this combination avoids mixing meat and dairy. This option aligns with kosher dietary restrictions.
C. Shrimp salad and tomato soup with milk: Shrimp is a shellfish and is not kosher. Kosher dietary laws prohibit the consumption of shellfish and other non-scaled seafood.
D. Bacon and cheese quiche with milk: Bacon is derived from pork, which is forbidden in kosher diets. Additionally, this meal mixes meat and dairy, which is also not permitted under kosher rules.
Correct Answer is A
Explanation
A. Weighing clients is within the scope of an assistive personnel’s role, provided they have been properly trained in using facility equipment and understand the procedure. The nurse retains responsibility for ensuring the accuracy of the data and interpreting it.
B. This response focuses on the nurse’s ability rather than appropriate delegation. Delegating tasks helps manage time and resources effectively when delegation is safe and appropriate.
C. Weighing clients does not require nursing judgment; it is a routine, stable task that is appropriate for delegation under the right conditions.
D. Weights obtained on new clients may be needed before a full nursing assessment, but initial assessments must be performed by a nurse, not delegated to APs.
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