A nurse is preparing to obtain a wound culture on a newly admitted client. What technique demonstrates proper collection of a wound culture?
Swab the drainage from the removed dressing.
Swab the pool of exudate in the wound bed before irrigating.
Swab the beefy red tissue in the wound bed after irrigating.
Swab the skin surrounding the wound prior to wound care.
The Correct Answer is C
A. Swab the drainage from the removed dressing: Collecting a specimen from the dressing may contain contaminants from the external environment or surrounding skin, which can result in inaccurate culture results. The dressing does not reliably reflect the microbial environment of the wound itself.
B. Swab the pool of exudate in the wound bed before irrigating: Swabbing pooled exudate can yield superficial organisms that may not represent the pathogens causing infection. The exudate often contains debris, surface bacteria, and environmental contaminants, making it a less accurate source for culture.
C. Swab the beefy red tissue in the wound bed after irrigating: The proper technique involves first irrigating the wound to remove debris and surface contaminants, then swabbing the viable, granulating tissue. This ensures the culture sample reflects the organisms actively infecting the wound, increasing the accuracy of results for guiding targeted antimicrobial therapy.
D. Swab the skin surrounding the wound prior to wound care: Swabbing the periwound skin will collect normal skin flora rather than organisms in the wound itself. While skin assessment is important for hygiene and preventing infection, it does not provide clinically useful information about the wound infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Annual pap smear: Routine Pap smears are generally not recommended for women older than 65 who have had adequate prior screening and are not at high risk for cervical cancer. Continuing Pap smears in this age group offers minimal benefit for disease prevention, making it a lower priority compared with vaccinations that prevent life-threatening infections.
B. Pneumococcal immunization: Pneumococcal vaccination is highly recommended for adults aged 65 and older because aging increases susceptibility to pneumococcal infections, including pneumonia, bacteremia, and meningitis. Immunization significantly reduces morbidity and mortality in this population, making it the highest priority in older adults.
C. Annual mammogram: While mammography is important for early detection of breast cancer, current guidelines typically recommend individualized decision-making for women aged 70 and older, especially if life expectancy is limited or comorbidities exist. Vaccinations provide broader population-level protection against serious infections and thus take precedence.
D. Human papilloma virus (HPV) immunization: HPV vaccination is primarily targeted toward adolescents and young adults up to age 26, with some recommendations extending to 45. For adults over 70, HPV immunization does not provide meaningful protection, as exposure risk is low and immune response may be diminished, making it irrelevant for this age group.
Correct Answer is C
Explanation
A. Turn and reposition every 2 hours: Repositioning every 2 hours is a standard evidence-based intervention to prevent pressure injuries. Frequent repositioning relieves sustained pressure over bony prominences, improves tissue perfusion, and reduces the risk of skin breakdown.
B. Completing personal hygiene and apply skin barrier products: Maintaining skin hygiene and using moisture barrier creams protects skin from irritants such as urine, feces, and sweat. These measures help preserve skin integrity, reduce maceration, and prevent breakdown, making them appropriate preventive interventions.
C. Reposition the patient every 8 hours: Repositioning only every 8 hours is inadequate for pressure injury prevention. Prolonged pressure beyond 2–3 hours can compromise capillary blood flow, leading to tissue ischemia and increased risk of skin breakdown. This intervention does not align with current best practices and should be questioned.
D. Cushion vulnerable parts of the body and redistribute body weight: Using pillows, foam pads, or specialized mattresses to offload pressure on bony prominences is a recommended intervention. Redistributing weight reduces localized pressure, improves circulation, and minimizes the risk of developing pressure injuries.
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