A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?
Irrigate the wound with an antiseptic prior to obtaining the specimen.
Include intact skin at the wound edges in the culture.
Swab an area of skin away from the wound to identify the usual flora.
Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
The Correct Answer is D
A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.
B. While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.
C. This positioningis not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.
D. Ensuring the wheels of both the bed and the wheelchair are locked helps maintain stability and safety during the transfer process, reducing the risk of accidental movement and potential falls.
Correct Answer is D
Explanation
A. After removal of an indwelling urinary catheter, it is common for a client to experience urinary frequency for a few days. This is due to the bladder readjusting to its normal function.
B. Blood-tinged urine may occur after catheter removal, but it is not an expected outcome. It should be assessed and reported if it occurs.
C. Highly concentrated urine is not typically an expected outcome after catheter removal.
It may indicate dehydration or another issue that should be addressed.
D. Temporary urinary retention can occur after catheter removal, especially in older adults. This is why it's important to monitor the client for signs of retention, such as discomfort, restlessness, or a palpable bladder.
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