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80. A nurse is preparing to obtain a wound drainage specimen for culture from a client who has a nonhealing burn injury. In what order should the nurse collect this specimen? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Place the swab in the culture container.

Ensure the container is labeled with the date and time of collection.

Apply clean gloves.

Swab the wound in a zig-zag manner.

Answer and Explanation

The Correct Answer is C,D,A,B

Rationale:

Apply clean gloves: Wearing clean gloves is the first step to maintain standard precautions and prevent contamination during specimen collection.
Swab the wound in a zig-zag manner: This technique ensures that the swab collects cells and fluid from multiple areas of the wound, increasing the likelihood of detecting any microorganisms present.
Place the swab in the culture container: Immediately inserting the swab into the sterile container maintains the integrity of the specimen and prevents contamination.
Ensure the container is labeled with the date and time of collection: Labeling the specimen is critical for accurate identification and processing by the lab. It must be done after collection to ensure the label reflects the correct time and date.

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Correct Answer is B

Explanation

Rationale:
A. First-degree heart block: This rhythm shows a prolonged PR interval but maintains regular P waves before every QRS complex and a consistent rhythm. The presence of P waves and regularity rule out this option.

B. Atrial fibrillation: Atrial fibrillation is characterized by an irregularly irregular rhythm and absent or indistinct P waves due to disorganized atrial electrical activity. A heart rate of 98/min with no clear P waves fits the criteria for this dysrhythmia.

C. Complete heart block: Complete (third-degree) heart block features a complete dissociation between atrial and ventricular activity, with P waves and QRS complexes occurring independently. It typically presents with a bradycardic rhythm, not near 98/min.

D. Ventricular tachycardia: Ventricular tachycardia presents with a rapid, regular rhythm and wide QRS complexes. It usually lacks P waves but is typically much faster than 98/min, often ranging from 140 to 200 beats/min.

A. A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin. B. A client who has Meniere’s disease and cannot safely ambulate due to vertigo. C. A client who had a stroke and cannot eat or drink without choking. D. A client whose medications to manage Parkinson’s disease are no longer effective.

Correct Answer is D

Explanation

Rationale:
A. A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin: This situation requires case management or social work referral to assist with access to medications and insurance. It does not indicate the need for palliative care, as diabetes is a chronic condition that can be managed effectively with proper support.

B. A client who has Meniere’s disease and cannot safely ambulate due to vertigo: While vertigo significantly affects quality of life, it is not life-limiting. This client would benefit more from physical therapy, home safety evaluation, and symptom management, rather than palliative care services.

C. A client who had a stroke and cannot eat or drink without choking: This client may need speech therapy, nutritional support, or possibly enteral feeding, but not necessarily palliative care unless their overall prognosis is poor or complications are expected to worsen.

D. A client whose medications to manage Parkinson’s disease are no longer effective: Palliative care is appropriate for clients with progressive, life-limiting illnesses like advanced Parkinson’s disease, especially when symptoms can no longer be adequately controlled with standard treatments. It focuses on comfort, quality of life, and support for complex symptom management.

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80. A nurse is preparing to obtain a wound drainage specimen for culture from a client who has a nonhealing burn injury. In what order should the nurse collect this specimen? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document?

Correct Answer is B

Explanation

A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care?

Correct Answer is D

Explanation

A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching?

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