A provider has ordered a wound culture for a client with a nonhealing wound. What is the nurse's first action?
Put on nonsterile gloves
Gently remove the soiled dressings
Irrigate the wound
Label the specimen tube
The Correct Answer is A
Choice A reason: Putting on nonsterile gloves is the first action that the nurse should take before performing a wound culture. This is to protect the nurse from exposure to blood and body fluids and to prevent crosscontamination. Nonsterile gloves are sufficient for wound care as long as the wound is not sterile or infected.
Choice B reason: Gently removing the soiled dressings is the second action that the nurse should take after putting on nonsterile gloves. This is to expose the wound and prepare it for irrigation and culture. The nurse should discard the soiled dressings in a biohazard bag and observe the wound for any signs of infection, such as redness, swelling, or odor.
Choice C reason: Irrigating the wound is the third action that the nurse should take after removing the soiled dressings. This is to cleanse the wound and remove any debris or bacteria. The nurse should use sterile normal saline or an antiseptic solution as prescribed by the provider and irrigate the wound with a syringe or a spray bottle. The nurse should avoid touching the wound with the irrigation device and collect the runoff in a basin or a towel.
Choice D reason: Labeling the specimen tube is the last action that the nurse should take after irrigating the wound and obtaining the culture. This is to ensure that the specimen is correctly identified and processed by the laboratory. The nurse should label the tube with the client's name, date, time, and site of the wound. The nurse should also document the procedure and the wound assessment in the client's chart.
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Correct Answer is C
Explanation
Choice A reason: This is not the best intervention because it is timeconsuming and may not be feasible in some situations. Writing down the message can also be impersonal and may not convey the tone or emotion of the speaker. The nurse should use verbal communication as much as possible and supplement it with nonverbal cues, such as gestures, facial expressions, and eye contact.
Choice B reason: This is an incorrect intervention because it can be annoying and ineffective. Talking loudly in the impaired ear can cause discomfort and distortion of the sound. It can also damage the remaining hearing in the ear. The nurse should not shout or raise their voice, but rather speak at a normal volume and enunciate clearly.
Choice C reason: This is the best intervention because it enhances the quality and clarity of the verbal message. Speaking slowly and clearly while facing the client allows the client to see the nurse's mouth movements and facial expressions, which can help them understand the words and the meaning. The nurse should also avoid covering their mouth or chewing gum while speaking.
Choice D reason: This is not the best intervention because it can be inconvenient and impractical. Talking in a regular voice in the good ear may require the nurse to move around the client or position themselves in a certain way. It can also make the client feel isolated or singled out. The nurse should try to communicate with the client in a way that is comfortable and respectful for both parties.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect answer because a pathogenic infection is caused by a microorganism that can cause disease in a healthy host. Pathogens are usually able to overcome the host's immune defenses and cause symptoms and damage. Examples of pathogenic infections are strep throat, tuberculosis, and malaria.
Choice B reason: This is the correct answer because an opportunistic infection is caused by a microorganism that normally does not cause disease in a healthy host, but can take advantage of a weakened immune system and cause serious illness. Opportunistic infections are common and often lifethreatening complications of HIV infection, as the virus destroys the CD4 cells that help fight infections. Examples of opportunistic infections are pneumocystis pneumonia, candidiasis, and toxoplasmosis.
Choice C reason: This is an incorrect answer because a nosocomial infection is acquired in a health care setting, such as a hospital, clinic, or nursing home. Nosocomial infections are usually caused by microorganisms that are resistant to antibiotics and can spread easily among patients and staff. Examples of nosocomial infections are methicillinresistant Staphylococcus aureus (MRSA), Clostridioides difficile (C. diff), and urinary tract infections.
Choice D reason: This is an incorrect answer because a root cause infection is not a valid term in medical terminology. A root cause is the underlying factor or reason that leads to a problem or outcome. A root cause analysis is a process of identifying and addressing the root causes of a problem or event, such as an infection, to prevent recurrence and improve quality and safety.
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