A nurse is collecting a culture specimen from a client's nonhealing wound. Which of the following actions should the nurse take first?

Remove clean gloves and apply sterile gloves.

Place the swab in the culture tube.

Irrigate the wound with 0.9% sodium chloride.

Rotate the swab over the sides of the wound.

Answer and Explanation

The Correct Answer is C

A. Remove clean gloves and apply sterile gloves: This step is important to prevent contamination but is not the first step.
B. Place the swab in the culture tube: This is the final step in the process, not the first.
C. Irrigate the wound with 0.9% sodium chloride: The first step before collecting a wound culture is to irrigate the wound with sterile 0.9% sodium chloride (normal saline) to remove surface debris, which could contain contaminants rather than the actual infectious organisms. This ensures a more accurate specimen by collecting bacteria from the wound bed rather than from surface contaminants.
D. Rotate the swab over the sides of the wound: This step is performed after irrigating the wound and wearing sterile gloves.

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Correct Answer is D

Explanation

A. Tingling in the toes: Tingling in the toes is not specific to CRPS. It might be a general symptom but is not a classic sign of CRPS.
B. 1+ dorsalis pedis pulse: A weak pulse might indicate reduced circulation but is not specific to CRPS. CRPS is more associated with pain, swelling, and changes in skin color or temperature.
C. Capillary refill of 3 seconds: A capillary refill time of 3 seconds is prolonged and suggests possible circulation issues, but it is not a specific manifestation of CRPS.
D. Increased edema of the foot: Increased edema of the foot is a common manifestation of CRPS. CRPS often presents with localized swelling, along with other symptoms like pain and changes in skin color or temperature.

A. "The client's postoperative antibiotic was administered." B. "The client's partner came to visit today." C. "At 2200, the client's IV fluid bag and tubing will need replacing." D. "Colonoscopy was performed 48 hours ago."

Correct Answer is C

Explanation

A. "The client's postoperative antibiotic was administered." While this information is important, it is not typically included in the change-of-shift report unless there were specific issues related to antibiotic administration (e.g., allergic reactions, missed doses).
B. "The client's partner came to visit today." While this information might be relevant to the client’s social and emotional well-being, it is not critical for the shift report regarding clinical care.
C. "At 2200, the client's IV fluid bag and tubing will need replacing." This statement is important for continuity of care and should be included in the report to ensure that the next shift is aware of necessary actions.
D. "Colonoscopy was performed 48 hours ago." This information is relevant for understanding the client’s postoperative status but is less immediate compared to other details such as current medication administration or upcoming needs.

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A nurse is collecting a culture specimen from a client's nonhealing wound. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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