A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first?
Swab the wound bed with a sterile cotton-tipped swab
Cleanse the area around the wound with sterile saline.
Don sterile gloves
Place the collection tube in a specimen bag.
The Correct Answer is B
A. Swabbing the wound bed is necessary to obtain the culture specimen, but it must not be done until after the wound and surrounding area have been cleansed. Swabbing an uncleaned wound will collect superficial skin flora and debris rather than the true pathogens causing the infection.
B. According to evidence-based practice and nursing guidelines for wound care, the nurse must first cleanse the wound and surrounding area with sterile saline (or an approved non-antiseptic cleanser) to remove exudate, topical medications, and normal skin flora. This ensures that the culture specimen reflects the actual microorganisms responsible for the internal wound infection, making it the highest priority first step.
C. Donning sterile gloves is an appropriate action to maintain surgical asepsis during a sterile dressing change or wound culture procedure, but it is not the first action. The nurse typically wears clean gloves to remove the old dressing and cleanse the wound before transitioning to sterile gloves, or performs hand hygiene before preparing the sterile culture kit.
D. Placing the collection tube into a biohazard specimen bag is a necessary final step performed after the specimen has been successfully collected, labeled, and sealed to ensure safe transport to the laboratory, so it cannot be the first action taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Basal cell carcinoma commonly presents as a small, translucent papule with rolled borders. It may have a pearly or shiny appearance and often develops on sun-exposed areas, such as the nose.
Choice B rationale: This description is more characteristic of melanoma, not basal cell carcinoma.
Choice C rationale: This description may be more indicative of squamous cell carcinoma.
Choice D rationale: This description does not align with the typical presentation of basal cell carcinoma.
Correct Answer is ["31.5"]
Explanation
Rationale: the anterior chest wall and abdomen accounts for 18%, the left upper limb 9 % (4.5% anteriorly and 4.5% posteriorly), and the right upper limb 4.5% (2.25% anteriorly and 2.25% posteriorly).
(18+9+4.5) =31.5%
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