A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first?

Swab the wound bed with a sterile cotton-tipped swab

Cleanse the area around the wound with sterile saline.

Don sterile gloves

Place the collection tube in a specimen bag.

Answer and Explanation

The Correct Answer is C

- A: Swabbing the wound bed is an essential step in obtaining a wound culture, but it is not the first action that should be taken. This step is performed after the wound has been cleansed to ensure that the sample is not contaminated with debris or bacteria from the surrounding skin.
- B: Cleansing the area around the wound with sterile saline is the correct first step. This action helps to remove any contaminants or debris from the wound surface, ensuring that the culture obtained is from the wound itself and not from the surrounding skin, which could lead to inaccurate results.
- C: Donning sterile gloves is a crucial step to maintain sterility during the procedure. However, it is not the first action because the nurse must first cleanse the wound area to prevent contamination of the culture specimen.
- D: Placing the collection tube in a specimen bag is done after obtaining the wound culture to transport the specimen to the laboratory. This is one of the final steps in the process, not the first.

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Correct Answer is C

Explanation

Choice A rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not question the charge nurse about care deficits.
Choice B rationale: The nurse should not include any opinions, judgments, or blame in the incident report, as this could be used as evidence in a legal case. Therefore, the nurse should not document what the nurse believes was the cause of ulcer development.
Choice C rationale: This is important because it provides factual information about the client's condition and perception of the event, which could help in identifying the factors that contributed to the ulcer development and preventing further complications.
Choice D rationale: Documenting in the client's medical record that the nurse completed an incident report is not the primary purpose of the incident report itself. Incident reports are internal documents used by the healthcare facility to track and investigate events. The documentation in the client's medical record should focus on the client's clinical condition, care provided, and response to treatment.

A. Heart rate 122/min B. Urinary output 25 mL/hr C. Difficulty swallowing D. Pain of 6 on a scale of 0 to 10

Correct Answer is C

Explanation

Choice A rationale: tachycardia is an expected finding in burns patients due to the increase in metabolic rate and fluid loss.
Choice B rationale: a urine output of 25 ml/hr is too low for an individual with burns hence the need for adequate fluid resuscitation. However, this is not a priority sign compared with the difficulty in breathing.
Choice C rationale: difficulty in swallowing is an indicator of airway edema which may compromise the patients breathing and oxygenation which may result in death. Therefore, the healthcare provider should be notified to assess the need for intubation.
Choice D rationale: Pain of 6 on a scale of 0 to 10 is moderate and is expected due to burns and can be managed with analgesics and nonpharmacological interventions.

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A nurse is obtaining an aerobic wound culture for a client. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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