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
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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Related Questions
Correct Answer is D
Explanation
A. "The client was intubated without complications.": While relevant to the surgical process, this detail is more critical in the operating or PACU setting and less essential for ongoing post-op care unless complications occurred.
B. "The client is a member of the board of directors.": This is not clinically relevant and violates the client’s confidentiality by sharing unnecessary personal information.
C. "There was a total of 10 sponges used during the procedure.": Sponge count is important intraoperatively, but it is not typically necessary in a hand-off unless a count discrepancy occurred.
D. "The estimated blood loss was 250 milliliters.": This is clinically relevant and necessary for postoperative monitoring. It informs the receiving nurse about potential volume loss and the need to monitor for signs of hypovolemia.
Correct Answer is B
Explanation
A. Ibuprofen: This NSAID can irritate the gastric lining and increase the risk of bleeding, making it inappropriate for clients with a history of peptic ulcers.
B. Acetaminophen: It is not an NSAID and does not affect the gastrointestinal lining, making it a safer option for pain relief in clients with peptic ulcer disease.
C. Ketorolac: Like other NSAIDs, ketorolac increases the risk of gastric bleeding and should be avoided in clients with peptic ulcers.
D. Aspirin: Aspirin is an NSAID and antiplatelet agent that can worsen peptic ulcers and increase bleeding risk, so it should not be used in this client.
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