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","C","E"]
Explanation
Choice A reason: Candidiasis is an opportunistic infection associated with AIDS. Candidiasis is a fungal infection caused by Candida species, which normally live in the mouth, throat, vagina, and intestines. In people with AIDS, the immune system is weakened and cannot control the growth of Candida, leading to oral thrush, esophagitis, vaginitis, or systemic candidiasis.
Choice B reason: Hodgkin's lymphoma is not an opportunistic infection associated with AIDS. Hodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the immune system. It is characterized by the presence of ReedSternberg cells, which are abnormal lymphocytes. The exact cause of Hodgkin's lymphoma is unknown, but it is not related to any specific infection.
Choice C reason: Pneumocystis jiroveci pneumonia is an opportunistic infection associated with AIDS. Pneumocystis jiroveci pneumonia is a fungal infection caused by Pneumocystis jiroveci, which normally lives in the lungs of healthy people without causing any symptoms. In people with AIDS, the immune system is weakened and cannot prevent the invasion of Pneumocystis jiroveci, leading to pneumonia, which is a serious and potentially fatal lung infection.
Choice D reason: Clostridium difficile is not an opportunistic infection associated with AIDS. Clostridium difficile is a bacterial infection caused by Clostridium difficile, which normally lives in the colon of healthy people without causing any problems. In some cases, the use of antibiotics can disrupt the normal balance of bacteria in the colon and allow Clostridium difficile to overgrow and produce toxins, leading to diarrhea, colitis, or pseudomembranous colitis. This infection can affect anyone, regardless of their HIV status.
Choice E reason: NonHodgkin's lymphoma is an opportunistic infection associated with AIDS. NonHodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the immune system. It is characterized by the presence of abnormal lymphocytes, which may be B cells, T cells, or natural killer cells. NonHodgkin's lymphoma is associated with several infections, such as EpsteinBarr virus, human herpesvirus 8, hepatitis C virus, and human Tcell leukemia virus, which may trigger the transformation of lymphocytes in people with AIDS.
Correct Answer is A
Explanation
Choice A reason: Using standard precautions is a practice that is recommended to prevent HIV transmission, because it is a set of guidelines that apply to all clients, regardless of their infection status, and that aim to prevent the exposure to blood, body fluids, or other potentially infectious materials. Standard precautions include hand hygiene, use of personal protective equipment, safe handling and disposal of sharps, environmental cleaning, and respiratory hygiene.
Choice B reason: Double gloving is not a practice that is recommended to prevent HIV transmission, because it is not proven to be more effective or safer than single gloving. Double gloving is a technique that involves wearing two pairs of gloves, one over the other, which may provide some extra protection against needlestick injuries or glove punctures, but may also reduce the tactile sensitivity, dexterity, or comfort of the wearer. Double gloving is not a routine practice, but rather an option for certain situations, such as highrisk procedures, long surgeries, or known HIVpositive clients.
Choice C reason: Applying hand sanitizer to gloves during cares is not a practice that is recommended to prevent HIV transmission, because it is not appropriate or hygienic. Applying hand sanitizer to gloves during cares is a practice that can damage the integrity and effectiveness of the gloves, as the alcohol or other chemicals can degrade the material, cause holes, or reduce the fit of the gloves. Applying hand sanitizer to gloves during cares can also create a false sense of security, as the gloves may still be contaminated or ineffective. Hand sanitizer should be applied to the hands before and after wearing gloves, not to the gloves themselves.
Choice D reason: Wearing a mask within three feet of the client is not a practice that is recommended to prevent HIV transmission, because it is not necessary or relevant. Wearing a mask within three feet of the client is a practice that is part of the droplet precautions, which are used to prevent the transmission of infections that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. HIV is not transmitted by respiratory droplets, but rather by sexual contact, blood, or other body fluids. Wearing a mask within three feet of the client may not provide any protection against HIV, and may also cause stigma or discrimination.
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.