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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Use salt substitutes to reduce your sodium intake.": Salt substitutes often contain potassium, which can accumulate to dangerous levels in clients with chronic kidney disease. Therefore, they should be avoided rather than recommended.
B. "Increase your fluid intake to 1,000 mL a day.": Clients on hemodialysis typically require fluid restrictions, not increases, to prevent fluid overload between dialysis sessions. Fluid allowances are individualized based on urine output and clinical status.
C. "Include phosphorus-rich foods in your diet.": Phosphorus levels tend to rise in clients with kidney failure, contributing to bone disease. These clients are advised to avoid phosphorus-rich foods like dairy, nuts, and cola beverages.
D. "Avoid food products that contain trans-fats.": Clients with chronic kidney disease are at increased risk for cardiovascular disease. Avoiding trans-fats, which raise LDL cholesterol and promote inflammation, supports heart health and is an appropriate dietary recommendation.
Correct Answer is D
Explanation
Rationale:
A. Hypotension: Circulatory overload typically causes hypertension rather than hypotension due to increased blood volume and pressure. Hypotension would be more consistent with a different transfusion reaction such as anaphylaxis or septic shock.
B. Flattened jugular veins: Jugular vein distention, not flattening, is a classic sign of circulatory overload. Distended neck veins indicate elevated central venous pressure from fluid excess.
C. Lethargy: While lethargy may occur with various conditions, it is not a specific or early sign of circulatory overload. More immediate symptoms include respiratory distress and cardiovascular changes.
D. Bounding pulse: A bounding pulse is a key sign of circulatory overload, reflecting increased stroke volume and elevated intravascular volume. It often occurs alongside hypertension, dyspnea, and jugular vein distention, especially in older adults with compromised cardiac function.
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