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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.
Correct Answer is B
Explanation
A. Hgb: A hemoglobin level of 11.1 mg/dL is lower than normal, indicating anemia, which could be concerning but might not be the most urgent issue compared to other findings.
B. Urinalysis results: Positive urine ketones indicate ketonuria, which is significant in the context of hyperemesis gravidarum and may reflect severe dehydration or malnutrition. This finding should be reported to the provider.
C. Intake: The client’s intake of 50% of the meal without emesis is a relevant detail but does not indicate a severe immediate issue compared to the urinalysis results.
D. Temperature: A temperature of 37.2° C (99° F) is slightly elevated but not extremely concerning in this context compared to other findings like ketonuria.
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