165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)

Assess the appearance of the wound

Place the swab in the culture tube

Cleanse the wound with 0.9% sodium chloride

Cover the wound with a sterile dressing

Obtain the specimen from granulation tissue of the wound

Answer and Explanation

The Correct Answer is A,C,E,B,D

A. Assess the appearance of the wound first to determine its condition and document characteristics such as drainage, size, and tissue type before collecting the specimen.

B. Place the swab in the culture tube immediately after obtaining the specimen to prevent contamination and preserve the sample.
C. Cleanse the wound with 0.9% sodium chloride to remove surface contaminants, which helps ensure the culture reflects true pathogens within the wound bed.
D. Cover the wound with a sterile dressing to protect the area from external contamination and promote healing after the specimen has been collected.

E. Obtain the specimen from granulation tissue of the wound, avoiding pooled drainage or necrotic areas, to ensure the most accurate culture results.

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Correct Answer is D

Explanation

A. Contraction intensity increased by ambulation: True labor contractions typically become stronger and more regular with ambulation, unlike false labor, which does not intensify with movement.
B. Slow change in dilation and effacement: Even slow cervical changes suggest true labor is occurring. In false labor, the cervix usually remains unchanged despite contractions.
C. Presence of bloody show: A bloody show indicates cervical changes and is commonly associated with the onset of true labor, not false labor.
D. Intermittent painless contractions: These are characteristic of false labor, often referred to as Braxton Hicks contractions, and do not result in cervical dilation or effacement.

A. Fill out an incident report. B. Report the incident to the nurse manager. C. Notify the provider. D. Measure the client's vital signs.

Correct Answer is D

Explanation

A. Fill out an incident report: While documentation is essential for quality improvement and accountability, it is not the immediate priority. The client’s safety must be addressed before any administrative action is taken.
B. Report the incident to the nurse manager: Notifying the manager is an important step in the reporting chain, but it should occur after ensuring the client is stable and receiving appropriate clinical care.
C. Notify the provider: The provider must be informed to assess for possible interventions or antidotes, but the nurse should first collect the client’s current clinical status to report meaningful information.
D. Measure the client's vital signs: Assessing the client’s condition is the first priority after a medication error. Vital signs provide critical information on the client’s immediate response and help guide the next steps in managing the error.

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165. A nurse is collecting a specimen for an aerobic culture from a client who has a draining pressure injury. Identify the sequence of actions the nurse should follow. (Move the Steps into the box on the right. placing them in the order of performance. use all the steps.)

Nursing Test Bank

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