A nurse is attending to a patient with a wound infection.
What should the nurse do when collecting a wound-drainage specimen for culture?
Swab an area of skin away from the wound to identify the usual flora.
Irrigate the wound with an antiseptic prior to obtaining the specimen.
Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
Include intact skin at the wound edges in the culture.
The Correct Answer is C
Choice A rationale
Swabbing an area of skin away from the wound to identify the usual flora is not the correct action. This would not provide a representative sample of the wound infection.
Choice B rationale
Irrigating the wound with an antiseptic prior to obtaining the specimen is not the correct action. This could potentially alter the results of the culture.
Choice C rationale
Cleansing the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen is the correct action. This helps to remove surface bacteria and ensures a more accurate culture result.
Choice D rationale
Including intact skin at the wound edges in the culture is not the correct action. This could contaminate the specimen with bacteria that are not part of the wound infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.
Choice B rationale
Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.
Choice C rationale
While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.
Choice D rationale
Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.
Correct Answer is D
Explanation
The correct answer is Choice D
Choice A rationale: Moral reasoning, including distinguishing right from wrong, requires abstract cognitive processing and internalization of social norms, typically emerging during the concrete operational stage around age 7. Toddlers are in Piaget’s sensorimotor to early preoperational phase, where egocentrism dominates and behavior is guided by immediate consequences rather than ethical principles. They lack the neurological maturity and social-cognitive integration required for moral discourse, making this milestone developmentally inappropriate for the toddler age group.
Choice B rationale: Performing simple chores involves task comprehension, motor coordination, and social cooperation, which are more consistently observed in preschool-aged children (4–5 years). Toddlers may imitate adult actions but lack sustained attention, impulse control, and fine motor precision needed for chore completion. Their psychosocial development is centered on autonomy and exploration, not structured responsibility. Expecting chore cooperation at this stage exceeds normative developmental expectations and may lead to frustration or behavioral resistance.
Choice C rationale: Printing letters and numbers requires advanced fine motor control, visual-motor integration, and symbolic cognition, typically achieved between ages 5 and 6. Toddlers are still developing basic hand-eye coordination and may engage in scribbling, but they lack the neuromuscular refinement and cognitive mapping needed for structured writing. Neurodevelopmental milestones do not support this skill in the toddler phase, making it scientifically inaccurate to expect printing behavior before preschool age.
Choice D rationale: By age 3, toddlers begin to tolerate brief separations from primary caregivers due to improved object permanence, emotional regulation, and social awareness. This aligns with Erikson’s autonomy vs. shame and doubt stage, where toddlers explore independence while maintaining secure attachment. Separation anxiety peaks around 9–18 months and typically declines by age 3. The ability to separate easily for short periods reflects healthy psychosocial development and is a scientifically appropriate expectation for toddlers.
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