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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Finding	Assessment	Rationale
Temperature: 38.6°C	Worsened	The temperature increased from 38.2°C to 38.6°C, suggesting worsening fever or infection.
Pulse oximetry: 95% on 40% O₂	Improved	The client’s oxygen saturation increased from 85% to 95%, though with supplemental O₂, showing improved oxygenation.
Respiratory rate: 22/min	Improved	RR decreased from 32 to 22, indicating better respiratory effort and less distress.
Blood pressure: 112/54 mmHg	Unchanged	Minimal change from 114/56 to 112/54; both readings are within similar ranges.
Mucous membrane color: pink	Improved	Pink mucous membranes indicate improved oxygenation and perfusion, compared to pale earlier.

A. Ask the client to cough every 4 hr. B. Decrease the head of the client's bed. C. Encourage the client to take deep breaths. D. Request a prescription for an opioid analgesic.

Correct Answer is C

Explanation

A. Ask the client to cough every 4 hr:
Coughing can help clear secretions, but doing so only every 4 hours is not sufficient for hypoxia. More immediate action is needed.

B. Decrease the head of the client’s bed:
Lowering the head of the bed reduces lung expansion and worsens oxygenation.

C. Encourage the client to take deep breaths:
Deep breathing improves alveolar expansion and oxygen exchange, which helps raise oxygen saturation.

D. Request a prescription for an opioid analgesic:
Opioids can depress respiratory drive, further lowering oxygen levels unless pain is clearly affecting breathing.

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A nurse is assisting with obtaining an aerobic wound culture for a client. Which of the following actions should the nurse recommend taking first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Exhibits For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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