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 ["B","C","E"]
Explanation
Choice A reason: Include many fresh fruits and vegetables in your diet is not a correct answer, because it may increase the risk of infection for the client with AIDS. Fresh fruits and vegetables may contain bacteria, parasites, or pesticides that can cause gastrointestinal or systemic infections in immunocompromised clients. The nurse should advise the client to wash, peel, or cook fruits and vegetables before eating them, or to avoid them altogether if they have diarrhea or low white blood cell counts.
Choice B reason: Drink at least 2 to 3 L of fluids per day is a correct answer, because it helps prevent dehydration, maintain electrolyte balance, and flush out toxins and waste products. Fluid intake is especially important for clients with AIDS who may experience fever, sweating, vomiting, diarrhea, or oral lesions that can cause fluid loss.
Choice C reason: Eat highcalorie foods is a correct answer, because it helps prevent weight loss, muscle wasting, and malnutrition. Clients with AIDS may have increased caloric needs due to increased metabolic rate, infection, inflammation, or medication side effects. Highcalorie foods can provide energy and support immune function.
Choice D reason: Lower your caloric intake is not a correct answer, because it can worsen the nutritional status and health outcomes of the client with AIDS. Lowering caloric intake can lead to weight loss, muscle wasting, malnutrition, and increased susceptibility to infections and complications. The nurse should encourage the client to meet or exceed their caloric needs based on their weight, activity level, and disease stage.
Choice E reason: Choose foods high in protein is a correct answer, because it helps maintain muscle mass, tissue repair, and immune function. Clients with AIDS may have increased protein needs due to increased protein breakdown, infection, inflammation, or medication side effects. Highprotein foods can provide amino acids and antibodies that are essential for immune response.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Ischemia is a cause of a pressure ulcer, because it means reduced blood flow to the tissues, which can lead to tissue hypoxia, necrosis, and ulceration. Ischemia can result from factors such as compression, friction, shear, or vascular disease.
Choice B reason: Immobility is a cause of a pressure ulcer, because it means prolonged pressure on the bony prominences, which can impair blood flow and cause ischemia, tissue damage, and ulceration. Immobility can result from factors such as paralysis, injury, illness, or sedation.
Choice C reason: Poor nutrition is a cause of a pressure ulcer, because it means inadequate intake or absorption of nutrients, such as protein, calories, vitamins, and minerals, which are essential for tissue repair and wound healing. Poor nutrition can result from factors such as anorexia, malabsorption, or poverty.
Choice D reason: Moisture is a cause of a pressure ulcer, because it means excessive wetness or dampness of the skin, which can weaken the skin barrier, increase the risk of infection, and delay wound healing. Moisture can result from factors such as incontinence, perspiration, or wound drainage.
Choice E reason: Adequate perfusion is not a cause of a pressure ulcer, but rather a protective factor. Adequate perfusion means sufficient blood flow to the tissues, which can prevent ischemia, tissue damage, and ulceration. Adequate perfusion can be promoted by factors such as regular repositioning, pressure relief, and exercise.
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