A nurse is assisting with obtaining an aerobic wound culture for a client. Which of the following actions should the nurse recommend taking first?
Cleanse the wound with sterile saline.
Don sterile gloves
Swab the wound bed with a sterile cotton-tipped swab
Place the collection tube in a specimen bag.
The Correct Answer is A
A. Cleanse the wound with sterile saline:
This removes surface contaminants, ensuring the specimen reflects organisms within the wound, not contaminants from the skin.
B. Don sterile gloves:
While sterile technique is important, cleansing the wound must occur before donning sterile gloves to prevent contaminating the site.
C. Swab the wound bed with a sterile cotton-tipped swab:
This is done after cleansing the wound to collect an accurate sample.
D. Place the collection tube in a specimen bag:
This is the final step after the specimen is collected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Replace the drainage plug after releasing hand pressure on the device:
Doing this allows air into the reservoir, preventing the vacuum effect. Plug should be replaced while still compressed.
B. Empty the reservoir once per day:
Reservoirs should be emptied at least every shift or when half full, not just once a day.
C. Fully recollapse the reservoir after emptying it:
This restores negative pressure, allowing continuous drainage and wound healing.
D. Irrigate the tubing with sterile normal saline solution at least once every 8 hr:
Irrigating the tubing is not standard care for closed-wound drains and can introduce infection.
Correct Answer is B
Explanation
A. Provide the client a sip of warm water and wait 5 min before measuring his oral temperature:
This does not reliably normalize oral temperature and can still affect the accuracy.
B. Wait 30 min and return to measure the client's oral temperature:
Eating or drinking cold or hot substances can alter the oral temperature reading. Waiting 15–30 minutes allows for an accurate measurement.
C. Proceed to measure the client’s oral temperature:
This can result in an inaccurate (falsely low) reading due to recent ice chips.
D. Document the inability to obtain an accurate reading of the client’s oral temperature:
This step would be appropriate only if the nurse was unable to return or use an alternative method, which is not the case here.
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