How should a nurse obtain a culture of a patient’s wound?

Gently swab the center of the wound after irrigating with sterile saline.

Obtain a sample of the drainage from the dressing on the wound.

Use a sterile swab to collect a sample from the wound.

Collect a tissue sample from the wound during a surgical procedure.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Irrigating with sterile saline before swabbing can dilute the wound specimen and reduce the accuracy of the culture results. This is because the saline can wash away some of the bacteria that are present in the wound, making it more difficult to identify the specific bacteria that are causing the infection.

Additionally, swabbing the center of the wound may not collect a representative sample of the bacteria present, as bacteria can often be found in higher concentrations at the edges of the wound. This is because the edges of the wound are often where the tissue is most damaged and where the bacteria are able to enter the body more easily.

Choice B rationale:

Obtaining a sample of the drainage from the dressing on the wound may not be as accurate as collecting a sample directly from the wound. This is because the drainage may contain bacteria from the surrounding skin or environment, which could contaminate the culture results.

Additionally, the drainage may not contain a representative sample of the bacteria present in the wound, as some bacteria may not be able to drain out of the wound.

Choice D rationale:

Collecting a tissue sample from the wound during a surgical procedure is the most accurate way to obtain a culture. However, this is not always feasible or necessary.

It is often possible to obtain an accurate culture by collecting a sample from the wound using a sterile swab. This is a less invasive procedure and can be done at the bedside.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

While checking intravenous lines for patency and redness is important, it's not the most immediate priority in the post- anesthesia care unit (PACU). Ensuring airway patency and adequate oxygenation takes precedence over IV assessment. Issues with IV lines can usually be addressed quickly if they arise, whereas compromised airway or breathing can rapidly lead to life- threatening complications.

Choice B rationale:

Assessment of nasogastric tubes and bowel sounds is also important, but it's not as urgent as checking the airway and breathing. Bowel sounds may be absent immediately after surgery due to anesthesia and bowel manipulation, and their presence or absence doesn't necessarily indicate an immediate problem. Similarly, nasogastric tubes can be checked and adjusted as needed after ensuring the patient's airway and breathing are stable.

Choice D rationale:

Checking the Foley catheter and surgical fluid intake is essential for monitoring fluid balance and renal function, but it's not a priority over assessing airway, breathing, and circulation (ABCs). Fluid status can be assessed and managed after ensuring the patient's respiratory and circulatory systems are functioning adequately.

Choice C rationale:

Checking the airway, lung sounds, and pulse oximetry is the most critical assessment in the PACU because it ensures that the patient is breathing effectively and has adequate oxygen saturation. This assessment addresses the primary ABCs of patient care:

Airway: The nurse will assess for any obstructions or potential for obstruction, such as swelling, secretions, or the tongue blocking the airway. They will also ensure proper positioning of the head and neck to maintain airway patency.

Breathing: The nurse will listen to lung sounds to evaluate air entry and identify any signs of respiratory distress, such as wheezing, crackles, or decreased breath sounds. They will also monitor respiratory rate and effort.

Circulation: Pulse oximetry measures oxygen saturation in the blood, providing a quick and non-invasive assessment of oxygenation status. It's essential to ensure adequate oxygen delivery to tissues and organs.

By prioritizing the assessment of airway, lung sounds, and pulse oximetry, the nurse can quickly identify and intervene in any respiratory or oxygenation issues, preventing potentially life-threatening complications.

A. The patient is experiencing a moderate allergic reaction and should improve shortly. B. These symptoms are probably due to food poisoning because very few patients have true allergic responses. C. The patient is having an anaphylactic reaction and emergency interventions should be started. D. The patient is having a mild reaction that can be treated easily with an antihistamine.

Correct Answer is C

Explanation

Rationale for Choice A:

Incorrect. While the patient is experiencing an allergic reaction, it is not moderate. The presence of difficulty breathing and a drop in blood pressure are signs of a severe, life-threatening anaphylactic reaction.

Anaphylaxis is a severe, rapid-onset allergic reaction that can lead to death if not treated promptly. It typically involves multiple body systems, including the skin, respiratory system, cardiovascular system, and gastrointestinal system.

Moderate allergic reactions typically present with localized symptoms such as hives, itching, and redness. They do not typically involve respiratory or cardiovascular compromise.

Rationale for Choice B:

Incorrect. The patient's symptoms are not consistent with food poisoning. Food poisoning typically causes gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal cramps. It does not typically cause hives, difficulty breathing, or a drop in blood pressure.

The timing of the symptoms, occurring 2 hours after receiving an antibiotic, strongly suggests an allergic reaction to the medication.

Rationale for Choice C:

Correct. The patient's symptoms are consistent with anaphylaxis, a severe allergic reaction that requires immediate emergency treatment.

Key features of anaphylaxis include:

Skin involvement (hives, itching, flushing, swelling)

Respiratory distress (difficulty breathing, wheezing, tightness in the chest) Cardiovascular compromise (drop in blood pressure, lightheadedness, fainting) Gastrointestinal symptoms (nausea, vomiting, diarrhea)

Swelling of the tongue or throat

Rationale for Choice D:

Incorrect. The patient's reaction is not mild and cannot be treated with an antihistamine alone. Antihistamines are effective for mild allergic reactions, but they are not sufficient to treat anaphylaxis.

Anaphylaxis requires immediate treatment with epinephrine, which is a life-saving medication that can reverse the effects of the allergic reaction.

View Question and Answer

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

How should a nurse obtain a culture of a patient’s wound?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The post-anesthesia care unit nurse receives a patient from the operating room. Which assessment will the nurse perform first?

Correct Answer is C

Explanation

The nurse notes that the patient is scratching and has hives 2 hours after receiving a dose of antibiotic medication.The patient soon starts having difficulty breathing and his blood pressure drops. What is the correct analysis of the patient’s condition?

Correct Answer is C

Explanation

The nurse is to administer 3 mL of medication intramuscularly to an adult patient. Which is the appropriate site for the injection?

Which term should a nurse use to describe a deep decubitus ulcer on a patient’s heel that is covered in thick necrotic tissue?

A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed due to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

The patient has a large red, blistered area on the left hip.Which pressure injury stage will be recorded in the patient’s chart?

If a patient’s insurance company declines to cover the cost of a brand-name drug, which version of the drug will the patient likely receive instead?

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse? (Select all that apply.)

For the Nursing Exam #3 (Winter 2023), which of the following is an example of allopathic treatment?

If a nurse needs to administer 3 mL of medication intramuscularly to an adult patient, which site should be used for the injection?