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 A

Explanation

A. Osteoarthritis Obesity increases the stress on weight-bearing joints, leading to degeneration and increased risk of osteoarthritis.
B. Emphysema This condition is primarily related to smoking and other respiratory irritants, not directly to obesity.
C. Hyperthyroidism Obesity is typically associated with hypothyroidism, not hyperthyroidism.
D. Hypotension Obesity is more commonly associated with hypertension (high blood pressure), not hypotension (low blood pressure).

A. Decrease in heart rate B. Increase in vagal nerve tone C. Decrease in respiratory rate D. Increase in muscle tone

Correct Answer is D

Explanation

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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