A nurse is collecting a culture specimen from a client's nonhealing wound. Which of the following actions should the nurse take first?

Remove clean gloves and apply sterile gloves.

Place the swab in the culture tube.

Irrigate the wound with 0.9% sodium chloride.

Rotate the swab over the sides of the wound.

Answer and Explanation

The Correct Answer is C

A. Remove clean gloves and apply sterile gloves: This step is important to prevent contamination but is not the first step.
B. Place the swab in the culture tube: This is the final step in the process, not the first.
C. Irrigate the wound with 0.9% sodium chloride: The first step before collecting a wound culture is to irrigate the wound with sterile 0.9% sodium chloride (normal saline) to remove surface debris, which could contain contaminants rather than the actual infectious organisms. This ensures a more accurate specimen by collecting bacteria from the wound bed rather than from surface contaminants.
D. Rotate the swab over the sides of the wound: This step is performed after irrigating the wound and wearing sterile gloves.

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Correct Answer is D

Explanation

A. Keep the client's bed in its highest position with the side rails up. Keeping the bed in its highest position increases the risk of falls, especially for a client with urinary incontinence who may attempt to get up quickly. This does not adhere to safety guidelines.
B. Provide adult diapers for the client to wear while in bed. While providing diapers may be necessary, it is not the primary safety intervention. It is more important to address the client's mobility and ensure they can safely access the bathroom.
C. Store the client's personal possessions in the closet in her room. Keeping the room tidy and ensuring personal items are stored safely can reduce clutter and fall risks but does not directly address incontinence management or safety goals.
D. Ask the client to give a return demonstration of how to use the call light. Ensuring the client knows how to use the call light is crucial for safety. It allows them to call for assistance when needed, reducing the risk of falls when they need to use the bathroom.

A. Whole grain cereal B. Chocolate ice cream C. Sliced bananas D. Hot coffee

Correct Answer is C

Explanation

A. Whole grain cereal: Not recommended. Whole grains can be high in insoluble fiber, which may worsen diarrhea.
B. Chocolate ice cream: Not recommended. Ice cream, especially chocolate-flavored, contains dairy and fat, which may exacerbate diarrhea.
C. Sliced bananas: Bananas are easy to digest, provide potassium, and can help firm up stools.
D. Hot coffee: Not recommended. Coffee is a stimulant and can irritate the gastrointestinal tract, potentially worsening diarrhea.

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A nurse is collecting a culture specimen from a client's nonhealing wound. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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