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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The dorsal gluteal site, also known as the dorsogluteal site, was once a common choice for intramuscular injections. However, it has fallen out of favor due to several concerns, including:
Risk of sciatic nerve injury: The sciatic nerve, the largest nerve in the body, runs deep within the gluteal region. Injections into the dorsal gluteal site have a higher risk of accidentally hitting this nerve, which can lead to pain, numbness, and weakness in the leg.
Difficulty in landmarking: Accurately locating the dorsal gluteal site can be challenging, especially in patients with excessive adipose tissue or those who are unable to position themselves properly. Incorrect injection placement can increase the risk of tissue damage and poor drug absorption.
Pain: The dorsal gluteal site is often more painful than other intramuscular injection sites, likely due to the presence of more nerve endings in the area.
Choice B rationale:
The deltoid muscle, located in the upper arm, is a common site for intramuscular injections, particularly for vaccines. However, it has limitations when it comes to administering larger volumes of medication:
Small muscle mass: The deltoid is a relatively small muscle, limiting the amount of medication that can be safely injected. It's generally recommended to inject no more than 1-2 mL of medication into the deltoid muscle.
Proximity to nerves and blood vessels: The deltoid muscle is located near the radial nerve and brachial artery. Improper injection technique could potentially injure these structures.
Choice C rationale:
The vastus lateralis muscle, located in the anterolateral aspect of the thigh, is considered the preferred site for intramuscular injections in adults when the volume of medication exceeds 2 mL. Here's why:
Large muscle mass: The vastus lateralis is a large, thick muscle, capable of accommodating larger volumes of medication (up to 5 mL).
Easy to access: The vastus lateralis is easily accessible and can be injected with the patient in a sitting or lying position.
Fewer nerves and blood vessels: The vastus lateralis has fewer major nerves and blood vessels compared to other injection sites, reducing the risk of injury.
Pain tolerance: Studies have shown that injections into the vastus lateralis are generally less painful than injections into the deltoid or gluteal muscles.
Choice D rationale:
The lateral piriformis muscle is not a recognized or recommended site for intramuscular injections. It's a deep muscle located within the pelvic region, making it difficult to access and posing a higher risk of injury to surrounding structures.
Correct Answer is A
Explanation
Choice A rationale:
Thick, creamy yellow discharge is a hallmark characteristic of purulent drainage. This type of drainage is commonly referred to as pus and is indicative of an infection within the wound. It is composed of white blood cells, dead bacteria, cellular debris, and inflammatory cells, giving it its characteristic opaque, thick, and yellowish appearance.
Purulent drainage is a significant clinical finding that requires prompt attention and intervention. Early identification and management of wound infections can prevent complications such as abscess formation, cellulitis, sepsis, and delayed wound healing.
Accurate documentation of purulent drainage is essential for communication among healthcare providers, monitoring wound progress, and guiding treatment decisions.
Choice B rationale:
Serosanguineous drainage is a mixture of serous fluid (clear, thin, and watery) and blood. It often appears pink or slightly red and is commonly observed in the early stages of wound healing or after dressing changes. While it may contain a small amount of blood, it lacks the thick, creamy consistency and yellow color that are characteristic of purulent drainage.
Choice C rationale:
Serous drainage is clear, thin, and watery, resembling plasma. It is a normal part of the wound healing process and is often seen in the early inflammatory stage. It does not contain the thick consistency or yellow coloration that are indicative of purulent drainage.
Choice D rationale:
Sanguineous drainage is composed primarily of fresh blood. It is bright red in color and typically indicates active bleeding within the wound. It does not exhibit the thick, creamy consistency or yellow hue that are characteristic of purulent drainage.
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