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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wearing synthetic clothing and woolen socks can generate static electricity, which poses a fire hazard in the presence of oxygen. The client should be advised to wear cotton or natural fiber clothing, which is less likely to generate static electricity.
B. "I will make sure my visitors smoke outside" is a correct statement. It is important to avoid smoking or open flames near oxygen equipment, as oxygen is highly flammable.
C. "I will be able to tell how much oxygen I'm getting by looking at the flowmeter" is a correct statement. The flowmeter indicates the rate of oxygen delivery in liters per minute.
D. "I should call my doctor if I find it harder to concentrate" is a correct statement.
Changes in mental alertness or concentration can be a sign of inadequate oxygenation and should be reported to the healthcare provider.
Correct Answer is B
Explanation
A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.
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