A nurse is preparing to culture a client's wound to determine if it is infected. Which of these steps should the nurse take?
Irrigate the wound with antiseptic, swab over granulation tissue, and replace swab in culture tube.
Irrigate the wound with saline, swab over granulation tissue, and replace swab in culture tube.
Irrigate the wound with antiseptic, swab over eschar, and replace swab in culture tube.
Swab over granulation tissue, replace swab in culture tube, and redress the wound.
The Correct Answer is B
A. Irrigate the wound with antiseptic, swab over granulation tissue, and replace swab in culture tube:
Antiseptics can kill surface organisms and affect culture results. Saline is preferred for accurate sampling.
B. Irrigate the wound with saline, swab over granulation tissue, and replace swab in culture tube:
Saline irrigation removes surface contaminants, and swabbing granulation tissue provides the best sample of infecting organisms.
C. Irrigate the wound with antiseptic, swab over eschar, and replace swab in culture tube:
Eschar is dead tissue and will not yield accurate infection results. Antiseptic also reduces accuracy.
D. Swab over granulation tissue, replace swab in culture tube, and redress the wound:
Skipping irrigation may allow contamination from surface bacteria, reducing accuracy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reattach the syringe and attempt to withdraw more water from the balloon:
Occasionally, fluid remains in the balloon due to backflow or incomplete deflation. Attempting to withdraw again is safe and often resolves the issue.
B. Ask the patient to bear down as the catheter is withdrawn with gentle pressure:
This may cause trauma if the balloon is not fully deflated. Not appropriate until it's confirmed that the balloon is completely empty.
C. Review the patient's chart to see how much water was inserted into the balloon:
Helpful for planning but not the immediate appropriate action. Reattempting aspiration is more time-sensitive and effective.
D. Explain to the patient that removal of the catheter may cause significant discomfort:
This does not solve the problem. The goal is to remove the catheter safely and with minimal discomfort.
Correct Answer is B
Explanation
A. 60:
This is the diastolic pressure, not the pulse pressure.
B. 80:
Pulse pressure = Systolic – Diastolic → 140 – 60 = 80. This is the correct calculation.
C. 140:
This is the systolic pressure, not the pulse pressure.
D. 200:
This is not a relevant value in this context and is mathematically incorrect.
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