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 D
Explanation
Choice A reason: Truck driver is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Carpal tunnel syndrome is a condition that occurs when the median nerve, which runs through the carpal tunnel in the wrist, is compressed or irritated by inflammation, swelling, or pressure. Truck drivers may experience other musculoskeletal problems, such as back pain, neck pain, or shoulder pain, due to prolonged sitting, vibration, or poor posture.
Choice B reason: Nursing assistant is an occupation that increases the risk for carpal tunnel syndrome, but it is not the best answer, because it involves other factors besides repetitive motion that can contribute to the condition. Nursing assistants may perform repetitive tasks, such as lifting, transferring, or bathing patients, that can strain the wrist and the median nerve. However, they may also experience other risk factors, such as trauma, infection, arthritis, or pregnancy, that can cause carpal tunnel syndrome.
Choice C reason: Elementary school teacher is not an occupation that increases the risk for carpal tunnel syndrome, because it does not involve repetitive or forceful flexion or extension of the wrist. Elementary school teachers may perform some tasks, such as writing, typing, or grading papers, that can involve wrist movement, but they are not likely to be frequent or intense enough to cause carpal tunnel syndrome. Elementary school teachers may experience other stressrelated problems, such as headaches, fatigue, or burnout, due to the demands of their work.
Choice D reason: Assembly line worker is the best answer, because it is an occupation that increases the risk for carpal tunnel syndrome, due to the nature and duration of the work. Assembly line workers may perform repetitive, forceful, or awkward movements of the wrist, such as twisting, bending, or gripping, that can cause compression or irritation of the median nerve. Assembly line workers may also work for long hours, with little rest or variation, that can exacerbate the condition.
Correct Answer is B
Explanation
Choice A reason: Stage 1 is a wound that involves only the epidermis, the outermost layer of the skin. It appears as a nonblanchable redness, warmth, or hardness on intact skin. It does not have any breakage or ulceration of the skin.
Choice B reason: Stage 2 is a wound that involves the epidermis and the dermis, the second layer of the skin. It appears as a shallow, open, reddened ulcer with a partialthickness loss of skin. It may have some serous exudate, but no slough or eschar. It may also present as a blister or abrasion.
Choice C reason: Stage 3 is a wound that involves the epidermis, the dermis, and the subcutaneous tissue, the third layer of the skin. It appears as a deep, open, reddened ulcer with a fullthickness loss of skin. It may have some slough or eschar, but no exposed bone, tendon, or muscle. It may also have tunneling or undermining of the wound edges.
Choice D reason: Stage 4 is a wound that involves the epidermis, the dermis, the subcutaneous tissue, and the underlying structures, such as bone, tendon, or muscle. It appears as a deep, open, reddened ulcer with a fullthickness loss of skin and tissue. It has exposed bone, tendon, or muscle, which may be visible or palpable. It may also have slough, eschar, necrosis, infection, or osteomyelitis.
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