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
Correct Answer is A
Explanation
Choice A rationale
Confusion or disorientation can be a normal part of the dying process. As the body systems start to shut down, changes in mental status, including confusion, can occur.
Choice B rationale
Sundowning is a phenomenon that is typically associated with dementia, particularly Alzheimer’s disease, and is characterized by confusion and agitation that gets worse in the late afternoon and evening. It is not specifically associated with the dying process.
Choice C rationale
While anxiety can occur at any stage of illness, it is not the most appropriate response in this context. The family member is specifically asking about confusion, not anxiety.
Choice D rationale
Needing more rest could be a part of the dying process, but it does not directly address the family member’s concern about confusion.
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