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.

Answer and Explanation

The Correct Answer is C

- A: Swabbing the wound bed is an essential step in obtaining a wound culture, but it is not the first action that should be taken. This step is performed after the wound has been cleansed to ensure that the sample is not contaminated with debris or bacteria from the surrounding skin.
- B: Cleansing the area around the wound with sterile saline is the correct first step. This action helps to remove any contaminants or debris from the wound surface, ensuring that the culture obtained is from the wound itself and not from the surrounding skin, which could lead to inaccurate results.
- C: Donning sterile gloves is a crucial step to maintain sterility during the procedure. However, it is not the first action because the nurse must first cleanse the wound area to prevent contamination of the culture specimen.
- D: Placing the collection tube in a specimen bag is done after obtaining the wound culture to transport the specimen to the laboratory. This is one of the final steps in the process, not the first.

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Correct Answer is D

Explanation

Choice A rationale: individuals with extensive burn wounds are highly likely to develop metabolic acidosis and not metabolic alkalosis due to the increased risk of tissue hypoxia, increased lactic acid levels, and renal failure.
Choice B rationale: low hemoglobin is not an expected finding in individuals with extensive burn wounds but instead increased hemoglobin levels are expected due to hemoconcentration resulting from excessive fluid loss.
Choice C rationale: A patient with extensive burn wounds is expected to have hypovolemia and not hypervolemia due to increased fluid loss from the burned tissues and increased capillary permeability.
Choice D rationale: hyperkalemia is a common finding in individuals with extensive burn wounds due to massive cell destruction which releases potassium from the intracellular compartment to the extracellular compartment.

A. Administer analgesics for pain B. Restrict visitors who have hot previously received a measles, mumps, and rubella vaccine. C. Place the client in protective isolation. D. Avoid the use of alcohol-based hand rubs.

Correct Answer is A

Explanation

Choice A rationale: Pain management is a crucial aspect of care for a client with herpes zoster (shingles). Administering analgesics can help alleviate pain and improve the client's overall comfort.
Choice B rationale: Herpes zoster is not spread through respiratory droplets, so restricting visitors based on their vaccination status is not necessary.
Choice C rationale: Protective isolation is not required for herpes zoster, as it is not highly contagious.
Choice D rationale: There is no need to avoid alcohol-based hand rubs in the care of a client with herpes zoster.

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A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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