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. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis and varicella, not bacterial meningitis.
B. Protective environment precautions are used for clients with severely compromised immune systems, not for preventing the spread of bacterial meningitis.
C. Contact: Contact precautions are used for infections spread by direct contact with the patient or their environment, such as MRSA or C. difficile, not bacterial meningitis.
D. Droplet: This is correct. Droplet precautions are required for bacterial meningitis as it spreads through large respiratory droplets.

A. The client has gastroesophageal reflux disease. B. The client is 62 years old. C. The client smokes half a pack of cigarettes per day. D. The client has urinary incontinence.

Correct Answer is D

Explanation

A. The client has gastroesophageal reflux disease. GERD does not typically increase the risk of falls.
B. The client is 62 years old. Age alone does not necessarily indicate a high fall risk, especially if the client is relatively healthy.
C. The client smokes half a pack of cigarettes per day. Smoking is a risk factor for many health issues but is not directly linked to an increased risk of falls.
D. The client has urinary incontinence. This is correct. Urinary incontinence increases the risk of falls, particularly if the client needs to frequently get up quickly to use the bathroom, potentially slipping or tripping.

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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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