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 ["A","B","D"]
Explanation
A. Crackles in the lungs: Pulmonary edema causes fluid accumulation in the alveoli, leading to crackles or rales heard during auscultation of the lungs.
B. Jugular vein distension: Increased pressure in the pulmonary circulation can lead to right-sided heart strain, resulting in visible jugular venous distension.
C. Persistent, dry cough: Cough in pulmonary edema is typically productive, often associated with pink, frothy sputum due to fluid leakage into the alveoli.
D. Frothy, blood-tinged sputum: A hallmark sign of pulmonary edema, this occurs as fluid mixed with blood leaks into the alveoli and airways due to high pulmonary capillary pressure.
E. Bradycardia: Pulmonary edema is typically associated with tachycardia as a compensatory response to hypoxia and impaired cardiac output, not bradycardia.
Correct Answer is C
Explanation
A. Polyuria: Polyuria results from hyperglycemia, where excess glucose in the bloodstream leads to osmotic diuresis. This causes the kidneys to excrete more water, increasing urination frequency. It is not a feature of hypoglycemia.
B. Fruity breath: Fruity-scented breath is due to ketone buildup in diabetic ketoacidosis, a complication of prolonged hyperglycemia. It signals metabolic acidosis rather than low blood sugar levels.
C. Diaphoresis: Diaphoresis occurs during hypoglycemia as the body releases epinephrine in response to falling glucose. This triggers sweating, tremors, and palpitations as part of the autonomic response.
D. Polyphagia: Polyphagia is a symptom of hyperglycemia, where cells are starved of glucose despite its presence in the blood. This leads to increased hunger, not typically seen in acute hypoglycemia.
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