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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Determine whether it is temporary or permanent is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Determining whether the compromised immunity is temporary or permanent is an important assessment, but it should be done after ensuring the safety and infection prevention of the client. Compromised immunity can be temporary or permanent, depending on the cause, such as medication, disease, or genetic disorder.
Choice B reason: Take the client's vital signs every four hours is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Taking the client's vital signs every four hours is an important monitoring, but it should be done after ensuring the safety and infection prevention of the client. Vital signs can indicate the general health status and the presence of infection or inflammation, such as fever, tachycardia, or hypotension.
Choice C reason: Teach the family members to receive the flu shot annually is not the nurse's priority action for a client with compromised immunity, because it is not the most urgent and relevant. Teaching the family members to receive the flu shot annually is an important education, but it should be done after ensuring the safety and infection prevention of the client. The flu shot is a vaccine that can protect the family members and the client from influenza, which can be a serious and potentially fatal infection for people with compromised immunity.
Choice D reason: Wash hands before entering the client's room is the nurse's priority action for a client with compromised immunity, because it is the most urgent and relevant. Washing hands before entering the client's room is a basic and essential infection prevention measure, which can protect the client from exposure to pathogens that can cause infection. People with compromised immunity have a weakened or impaired immune system, which makes them more susceptible and vulnerable to infection.
Correct Answer is C
Explanation
Choice A reason: "In order to avoid flareups of Raynaud's, ensure to keep cool." is not a correct answer, because it can worsen the symptoms of Raynaud's phenomenon. Raynaud's phenomenon is a condition that causes the blood vessels in the fingers and toes to narrow and spasm in response to cold or stress, resulting in reduced blood flow and color changes. Keeping cool can trigger or aggravate the spasms and decrease the blood flow.
Choice B reason: "In order to avoid flareups of Raynaud's, ensure you wear sunscreen." is not a correct answer, because it is not related to Raynaud's phenomenon. Sunscreen is a protective measure for clients with lupus, who may have increased sensitivity to ultraviolet rays and increased risk of skin damage and flareups. However, sunscreen does not prevent or treat Raynaud's phenomenon, which is caused by cold or stress, not by sun exposure.
Choice C reason: "In order to avoid flareups of Raynaud's, ensure you wear gloves in winter." is a correct answer, because it can help prevent or reduce the symptoms of Raynaud's phenomenon. Wearing gloves in winter can keep the hands warm and prevent the blood vessels from narrowing and spasming due to cold. This can improve the blood flow and prevent color changes, numbness, pain, or ulcers in the fingers.
Choice D reason: "In order to avoid flareups of Raynaud's, ensure you brush your teeth for two minutes." is not a correct answer, because it is not related to Raynaud's phenomenon. Brushing the teeth for two minutes is a good oral hygiene practice that can prevent dental problems, such as plaque, cavities, or gingivitis. However, brushing the teeth does not affect the blood vessels in the fingers and toes, nor does it prevent or treat Raynaud's phenomenon.
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