Nokea
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
- A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Include intact skin at the wound edges in the culture.
- D. Swab an area of skin away from the wound to identify normal flora.
Correct Answer: A
Rationale: The correct answer is A: Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. This step is essential to remove debris and contaminants from the wound, ensuring that the specimen obtained is not contaminated. Cleansing with a normal saline solution helps to minimize the risk of introducing outside pathogens into the culture sample. It also helps to provide a more accurate representation of the microorganisms present specifically within the wound.
Choices B, C, and D are incorrect. Choice B suggests using an antiseptic, which may interfere with the accuracy of the culture results. Choice C is incorrect because intact skin should not be included in the culture sample, as it does not reflect the microorganisms present in the wound. Choice D is incorrect as swabbing an area away from the wound will not provide relevant information about the wound infection.
You may also like to solve these questions
A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Grasping a fold of skin on the client's forearm or near the sternum is the appropriate method to assess skin turgor. Skin turgor is the skin's ability to return to normal after being pinched. By grasping the skin and observing how quickly it returns to its original state, the nurse can assess the client's hydration status accurately. This method is commonly used and recommended for assessing skin turgor.
Incorrect Choices:
A: Lightly palpating the skin using the fingertips does not provide an accurate assessment of skin turgor.
B: Pressing the skin over the client's ankle bone is not the standard method for assessing skin turgor.
C: Observing for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen is unrelated to assessing skin turgor and indicates a different condition.
A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?
- A. Cool skin
- B. Numbness
- C. Pallor
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. Thrombophlebitis is inflammation of a vein with a blood clot, leading to impaired blood flow. Edema, or swelling, is a common symptom due to the obstruction of blood flow. This results in fluid accumulation in the affected area. Cool skin, numbness, and pallor are not typical findings in thrombophlebitis. Cool skin and numbness are more indicative of nerve or circulation issues, while pallor suggests reduced blood flow but is not a common finding in thrombophlebitis.
While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?
- A. A systolic murmur
- B. A third heart sound (S3)
- C. An expected heart sound
- D. A fourth heart sound (S4)
Correct Answer: A
Rationale: The correct answer is A: A systolic murmur. Turbulence between S1 and S2 indicates a heart sound occurring during systole. Systolic murmurs are abnormal heart sounds heard between S1 and S2, often indicating a problem with the heart valves. S3 and S4 heart sounds occur after S2 and are associated with ventricular filling abnormalities. An expected heart sound would not exhibit turbulence. Therefore, the correct choice is A.
A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?
- A. Weak pulse
- B. Bradycardia
- C. Hypertension
- D. Distended neck veins
Correct Answer: A
Rationale: A weak, thready pulse is a classic sign of hypovolemia. Bradycardia and hypertension are more common with fluid overload.
A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?
- A. I will call the anesthesiologist right away.
- B. Can you tell me more about this concern?
- C. You have nothing to be concerned about. You have a competent anesthesiologist.
- D. I had a similar procedure and definitely received enough anesthesia.
Correct Answer: B
Rationale: Asking the client to elaborate allows for exploration of their concerns and reassurance through proper information.