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
Explanation
A. “It sounds like you're saying that you feel uncomfortable around others.": This therapeutic response reflects the client's feelings and encourages further expression, showing empathy without judgment or assumption.
B. “How long have you struggled with your weight?": This question shifts the focus to the client’s weight history rather than their current emotional distress, which may feel dismissive or overly clinical.
C. “Have you always felt uncomfortable being overweight?": This response makes assumptions about the client's feelings and can come across as insensitive, which may inhibit open communication.
D. “Let's discuss some weight loss strategies that might work for you.”: Offering solutions too early may invalidate the client’s emotions and shift the focus away from addressing their immediate feelings of embarrassment and discomfort.
Correct Answer is D
Explanation
A. Contraction intensity increased by ambulation: True labor contractions typically become stronger and more regular with ambulation, unlike false labor, which does not intensify with movement.
B. Slow change in dilation and effacement: Even slow cervical changes suggest true labor is occurring. In false labor, the cervix usually remains unchanged despite contractions.
C. Presence of bloody show: A bloody show indicates cervical changes and is commonly associated with the onset of true labor, not false labor.
D. Intermittent painless contractions: These are characteristic of false labor, often referred to as Braxton Hicks contractions, and do not result in cervical dilation or effacement.
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