A nurse is attending to a patient with a wound infection.
What should the nurse do when collecting a wound-drainage specimen for culture?

Swab an area of skin away from the wound to identify the usual flora.

Irrigate the wound with an antiseptic prior to obtaining the specimen.

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

Include intact skin at the wound edges in the culture.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Swabbing an area of skin away from the wound to identify the usual flora is not the correct action. This would not provide a representative sample of the wound infection.

Choice B rationale

Irrigating the wound with an antiseptic prior to obtaining the specimen is not the correct action. This could potentially alter the results of the culture.

Choice C rationale

Cleansing the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen is the correct action. This helps to remove surface bacteria and ensures a more accurate culture result.

Choice D rationale

Including intact skin at the wound edges in the culture is not the correct action. This could contaminate the specimen with bacteria that are not part of the wound infection.

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Correct Answer is A

Explanation

Choice A rationale

Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.

Choice B rationale

Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.

Choice C rationale

Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.

Choice D rationale

Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.

A. Notify the surgeon that the patient wishes to withdraw informed consent for the procedure. B. Inform the surgical team to cancel the patient’s surgery. C. Proceed with preparation of the patient for the surgical procedure. D. Remind the patient that a signed informed consent form is a legally binding document.

Correct Answer is A

Explanation

Choice A rationale

The patient has the right to withdraw their informed consent at any time, even after signing the consent form. This is a fundamental principle of patient autonomy and respect for the individual’s rights. The nurse should respect the patient’s decision and notify the surgeon that the patient wishes to withdraw informed consent for the procedure. This allows the healthcare team to reassess the situation, provide further information if necessary, and make appropriate adjustments to the care plan.

Choice B rationale

While informing the surgical team to cancel the surgery might be a subsequent step, it is not the immediate action the nurse should take. The first action should be to respect the patient’s autonomy and communicate their decision to the surgeon.

Choice C rationale

Proceeding with the preparation of the patient for the surgical procedure against their expressed wishes would be a violation of the patient’s rights. It is essential to respect the patient’s autonomy and their right to make decisions about their own healthcare.

Choice D rationale

Reminding the patient that a signed informed consent form is a legally binding document is incorrect. Informed consent is not a contract, and the patient has the right to withdraw consent at any time. The purpose of informed consent is to ensure that the patient understands the procedure, its risks and benefits, and alternatives, and makes an informed decision.

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A nurse is attending to a patient with a wound infection.What should the nurse do when collecting a wound-drainage specimen for culture?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult patient with left-sided heart failure. What assessment findings should the nurse expect?

Correct Answer is A

Explanation

A nurse has completed an informed consent form with a patient.The patient then states, “I have changed my mind and do not want to have the procedure done.”. What action should the nurse take?

Correct Answer is A

Explanation

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A nurse is attending to a patient with a wound infection.
What should the nurse do when collecting a wound-drainage specimen for culture?