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 A
Explanation
A. Place the client’s arm above the level of the heart:
The arm should be at heart level. Positioning it above the heart can lead to a falsely low BP reading.
B. Check the instrument gauge to ensure the reading starts at zero:
This ensures that the starting point is accurate, avoiding false readings.
C. Center the cuff bladder over the brachial artery:
Correct placement of the cuff ensures accurate compression of the artery during measurement.
D. Wrap the blood pressure cuff snugly around the arm:
The cuff should be snug but not tight, which helps in getting an accurate reading.
Correct Answer is C
Explanation
A. Palpate the client’s pulse at the third intercostal space:
The apical pulse is at the fifth intercostal space, midclavicular line-not the third. The third is not standard for pulse assessment.
B. Ask the client to perform the Valsalva maneuver:
This can be used in arrhythmias like supraventricular tachycardia but is not appropriate for assessment of irregular rhythm.
C. Auscultate the client’s apical pulse:
This is the most accurate way to assess an irregular pulse, especially for one full minute.
D. Check the client’s heart rate for 30 sec:
When a rhythm is irregular, you must assess for a full minute, not 30 seconds.
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