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","B","D","E"]
Explanation
Choice A rationale: Hyperlipidemia, particularly elevated cholesterol levels, can be associated with impaired wound healing. High cholesterol levels can contribute to atherosclerosis, leading to reduced blood flow to the wound site. Adequate blood supply is crucial for delivering oxygen and nutrients essential for the healing process.
Choice B rationale: Diabetes mellitus is a well-known risk factor for delayed wound healing. High blood sugar levels can impair the function of white blood cells, reduce collagen formation, and impair the overall healing process. Furthermore, individuals with diabetes are more prone to infections and may experience slower wound closure.
Choice C rationale: Medication history alone does not provide specific information about factors that directly affect wound healing. However, certain medications, such as corticosteroids or immunosuppressive drugs, may impact the healing process.
Choice D rationale: High cholesterol levels can contribute to atherosclerosis, leading to reduced blood flow to the wound site. Adequate blood supply is crucial for delivering oxygen and nutrients essential for the healing process.
Choice E rationale: Prealbumin is a marker of protein status and nutritional adequacy. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing. Adequate protein intake is crucial for collagen synthesis and overall tissue repair.
Correct Answer is B
Explanation
Choice A rationale: While age can influence the overall prognosis and response to treatment, the location of the burn is more critical in the immediate assessment of severity.
Choice B rationale: The priority when assessing the severity of burns is the location of the burn. Burns to certain areas, such as the face, neck, or major joints, can be more critical due to the potential for complications, including impairment of breathing, vision, or mobility. Burns to these areas may require prompt intervention and closer monitoring to ensure early mitigation of the above complications
Choice C rationale: While understanding the cause is important for prevention and future education, it is not the immediate priority in assessing the severity of the current burn.
Choice D rationale: While medical history may impact the overall treatment plan, it is not the primary factor in the initial assessment of burn severity.
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