A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

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

Include intact skin at the wound edges in the culture.

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

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

Answer and Explanation

The Correct Answer is D

A.   Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B.   Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C.   Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D.   Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.

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Correct Answer is ["A","B","D","E"]

Explanation

A. More difficulty seeing due to a greater sensitivity to glare is a common age-related change in vision.

B. Dehydration of intervertebral discs can occur with aging, leading to decreased flexibility and potentially contributing to back pain.

C. While systolic blood pressure may increase with age, decreased systolic blood pressure is not a typical age-related change.

D. Decreased cough reflex is an expected change, which can lead to an increased risk of respiratory infections in older adults.

E. Decreased bladder capacity is an expected age-related change due to changes in the bladder muscles and elasticity of the tissues. This can contribute to increased frequency of urination in older adults.

A. Instruct the client to tighten muscle groups for a short period, then relax. B. Move the client's limbs through their complete range of motion. C. Ask the client to move her arms and legs while applying slight resistance. D. Have the client move each limb independently through its complete range of motion.

Correct Answer is A

Explanation

A. Isometric exercises involve contracting or tensing muscles without actually moving the joint. Instructing the client to tighten muscle groups for a short period and then relax is the correct approach for isometric exercises. This action helps activate and strengthen specific muscle groups without moving the joints.
B. Moving the client's limbs through their complete range of motion is known as passive range of motion exercises. These exercises are important for maintaining joint flexibility but are not isometric.
C. Asking the client to move her arms and legs while applying slight resistance is known as resisted range of motion exercises. These exercises involve active movement against resistance and are not considered isometric.
D. Having the client move each limb independently through its complete range of motion is known as active range of motion exercises. These exercises involve voluntary
movement of each joint through its full range of motion and is not isometric.

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A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

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A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?