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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 D

Explanation

Rationale:

A. Dependent edema: This occurs due to fluid buildup in the peripheral tissues, which is typically caused by right-sided heart failure. It reflects systemic venous congestion rather than pulmonary issues associated with left-sided failure.

B. Jugular distention: Jugular venous distention is a sign of increased central venous pressure and is more often associated with right-sided heart failure, not the pulmonary congestion seen in left-sided failure.

C. Weight gain: Weight gain from fluid retention is more indicative of right-sided heart failure, which causes systemic congestion; it is not a primary manifestation of left-sided heart failure.

D. Frothy sputum: Frothy, often pink-tinged sputum results from pulmonary edema caused by left-sided heart failure. Blood backs up into the lungs due to poor left ventricular function, leading to fluid leakage into the alveoli.

A. Coughing B. Flat neck veins C. Use of accessory muscles D. Presence of coarse crackles

Correct Answer is C

Explanation

Rationale:
A. Coughing: While coughing is a common symptom of asthma, it is not specific to status asthmaticus. It can occur during mild, moderate, or severe asthma episodes and does not necessarily indicate life-threatening severity.

B. Flat neck veins: Flat neck veins are not characteristic of status asthmaticus. In severe respiratory distress, the client may show signs of increased intrathoracic pressure, which can lead to distended neck veins rather than flat ones.

C. Use of accessory muscles: The use of accessory muscles to breathe is a sign of severe respiratory distress and indicates that the client is struggling to maintain adequate ventilation. This is a hallmark of status asthmaticus, a life-threatening condition requiring immediate intervention.

D. Presence of coarse crackles: Coarse crackles are more commonly associated with fluid in the lungs, such as in pneumonia or heart failure. In status asthmaticus, breath sounds may be diminished or absent due to severe airway obstruction, rather than producing crackles.

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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 who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure?

Correct Answer is D

Explanation

An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?

Correct Answer is C

Explanation

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