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 B

Explanation

A. Ask the staff members to speak in much quieter tones. This does not fully address the issue. HIPAA regulations prohibit discussing patient information in public areas regardless of the volume.
B. Tell the staff members to stop discussing confidential information about this client. This is correct. This action directly addresses the breach of confidentiality and promotes HIPAA regulations by stopping the inappropriate discussion.
C. Alert the facility's attorney about the staff members' breach of confidentiality. This action may be excessive and is not the immediate step needed to stop the breach. Reporting to a supervisor or manager is more appropriate.
D. Ignore the situation because there is no one close by to hear the staff members' discussion. This is incorrect. Ignoring the situation does not comply with HIPAA regulations, which require confidentiality regardless of whether anyone is nearby.

A. Older adults have difficulty maintaining friendships. B. Older adults are completing Erikson's developmental task of integrity vs despair. C. Older adults are less involved in political and community activities. D. Older adults are in Piaget's developmental stage of concrete operations.

Correct Answer is B

Explanation

A. Older adults have difficulty maintaining friendships. This statement is not universally true and can be misleading. While some older adults may face challenges in maintaining friendships due to health issues or mobility limitations, many continue to have active social lives.
B. Older adults are completing Erikson's developmental task of integrity vs despair. According to Erikson’s stages of psychosocial development, older adults (65 years and older) face the challenge of reflecting on their lives and achieving a sense of integrity versus despair.
C. Older adults are less involved in political and community activities. This statement is not necessarily true. Many older adults remain active in political and community activities.
D. Older adults are in Piaget's developmental stage of concrete operations. The concrete operational stage is part of Piaget’s theory of cognitive development and typically applies to children aged 7 to 11 years.

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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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