A provider has ordered a wound culture for a client with a nonhealing wound. What is the nurse's first action?
Put on nonsterile gloves
Gently remove the soiled dressings
Irrigate the wound
Label the specimen tube
The Correct Answer is A
Choice A reason: Putting on nonsterile gloves is the first action that the nurse should take before performing a wound culture. This is to protect the nurse from exposure to blood and body fluids and to prevent crosscontamination. Nonsterile gloves are sufficient for wound care as long as the wound is not sterile or infected.
Choice B reason: Gently removing the soiled dressings is the second action that the nurse should take after putting on nonsterile gloves. This is to expose the wound and prepare it for irrigation and culture. The nurse should discard the soiled dressings in a biohazard bag and observe the wound for any signs of infection, such as redness, swelling, or odor.
Choice C reason: Irrigating the wound is the third action that the nurse should take after removing the soiled dressings. This is to cleanse the wound and remove any debris or bacteria. The nurse should use sterile normal saline or an antiseptic solution as prescribed by the provider and irrigate the wound with a syringe or a spray bottle. The nurse should avoid touching the wound with the irrigation device and collect the runoff in a basin or a towel.
Choice D reason: Labeling the specimen tube is the last action that the nurse should take after irrigating the wound and obtaining the culture. This is to ensure that the specimen is correctly identified and processed by the laboratory. The nurse should label the tube with the client's name, date, time, and site of the wound. The nurse should also document the procedure and the wound assessment in the client's chart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is correct and should be included in the nurse's teaching. It informs the client about the availability and benefits of adaptive devices that can enhance their home safety and independence. It also shows the nurse's empathy and respect for the client's needs and preferences.
Choice B reason: This statement is incorrect and should not be included in the nurse's teaching. It reflects the nurse's personal opinion and bias, and it may discourage the client from seeking help or expressing their pain. It also shows the nurse's lack of understanding and compassion for the client's condition and challenges.
Choice C reason: This statement is incorrect and should not be included in the nurse's teaching. It suggests an unsafe and hazardous practice that can increase the risk of falls and injuries for the client. It also shows the nurse's negligence and irresponsibility for the client's home safety.
Choice D reason: This statement is incorrect and should not be included in the nurse's teaching. It implies that the client is noncompliant and blames them for their home safety issues. It also shows the nurse's judgmental and accusatory attitude towards the client.
Correct Answer is C
Explanation
Choice A reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system. CD4+ Tcells and CD8+ Tcells are types of white blood cells that play a key role in the immune response. CD4+ Tcells are helper cells that activate and coordinate other immune cells, while CD8+ Tcells are cytotoxic cells that kill infected or abnormal cells. Human immunodeficiency virus infects and destroys CD4+ Tcells, which impairs the immune function and increases the risk of opportunistic infections and cancers. CD8+ Tcells are not directly affected by the virus, but they may increase in number as a compensatory mechanism to fight the infection. Therefore, most adults with human immunodeficiency virus will have lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells.
Choice B reason: Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and CD8+ Tcells are normal may indicate a condition that affects both types of Tcells, such as aplastic anemia, chemotherapy, radiation therapy, or immunosuppressive drugs.
Choice C reason: Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells is a laboratory value that most adults with human immunodeficiency virus will exhibit, because it reflects the effect of the virus on the immune system, as explained above. Lowerthannormal number of CD4+ Tcells and higher than normal CD8+ Tcells may indicate the progression of the infection and the severity of the immunodeficiency. The normal range of CD4+ Tcells is 500 to 1500 cells per microliter of blood, while the normal range of CD8+ Tcells is 150 to 1000 cells per microliter of blood.
Choice D reason: Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low is not a laboratory value that most adults with human immunodeficiency virus will exhibit, because it does not reflect the effect of the virus on the immune system, as explained above. Higherthannormal number of CD4+ Tcells and CD8+ Tcells are low may indicate a condition that affects CD8+ Tcells, such as leukemia, lymphoma, or corticosteroid therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.