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A nurse is attending to a patient with a wound infection. What should the nurse do when collecting a wound-drainage specimen for culture? What should the nurse do for wound culture collection?
- A. Swab an area of skin away from the wound to identify the usual flora.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.
- D. Include intact skin at the wound edges in the culture.
Correct Answer: C
Rationale: The correct answer is C: Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. This step is essential to ensure that the sample collected is not contaminated with external bacteria, which could lead to inaccurate results. By cleansing the wound with a sterile solution like saline, the nurse can remove debris and bacteria from the wound surface, increasing the likelihood of obtaining an accurate culture. Swabbing an area away from the wound (choice A) would not provide an accurate representation of the bacteria present in the wound. Irrigating the wound with an antiseptic (choice B) could potentially interfere with the culture results by killing the bacteria being tested for. Including intact skin at the wound edges in the culture (choice D) is unnecessary and could introduce contaminants. Overall, choice C is the most appropriate step to ensure a reliable wound culture.
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A nurse is caring for a patient who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for TPN?
- A. Serum glucose
- B. Serum calcium
- C. Serum magnesium
- D. Serum sodium
Correct Answer: A
Rationale: The correct answer is A: Serum glucose. When a patient is receiving TPN, monitoring serum glucose levels is crucial as TPN solutions contain high concentrations of glucose. Elevated glucose levels can lead to hyperglycemia, which can result in complications such as osmotic diuresis and hyperosmolar hyperglycemic state. Monitoring glucose levels helps in adjusting TPN infusion rates to maintain a stable blood glucose level.
Incorrect answers:
B: Serum calcium - Calcium levels are not directly affected by TPN and are not typically monitored specifically for patients receiving TPN.
C: Serum magnesium - While magnesium levels may be affected by TPN, glucose monitoring is more critical due to the high glucose content in TPN.
D: Serum sodium - Sodium levels are not directly influenced by TPN and are not typically monitored specifically for patients receiving TPN.
A nurse in a coronary care unit is admitting a patient who has had CPR following a cardiac arrest. The patient is receiving lidocaine IV at 2 mg/min. When the patient asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions? Why is the patient receiving lidocaine?
- A. Relieves pain.
- B. Slows intestinal motility.
- C. Dissolves blood clots.
- D. Prevents dysrhythmias.
Correct Answer: D
Rationale: The patient is receiving lidocaine to prevent dysrhythmias after experiencing a cardiac arrest. Lidocaine is a class IB antiarrhythmic drug that stabilizes the cardiac cell membrane, reducing the likelihood of abnormal electrical activity and dysrhythmias. It does not relieve pain, slow intestinal motility, or dissolve blood clots. Therefore, the correct answer is D, as it directly addresses the purpose of administering lidocaine in this specific clinical scenario.
A nurse is caring for a patient who has a new prescription for alendronate. Which of the following instructions should the nurse include? What instructions should the nurse include for alendronate?
- A. Take the medication with a full glass of milk.
- B. Take the medication at bedtime.
- C. Remain upright for 30 minutes after taking the medication.
- D. Take the medication with food.
Correct Answer: C
Rationale: The correct answer is C: Remain upright for 30 minutes after taking the medication. Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophageal irritation, so the patient must remain upright for at least 30 minutes after taking it to prevent reflux and irritation. Taking it with a full glass of milk (A) or with food (D) can decrease its absorption. Taking it at bedtime (B) may increase the risk of esophageal irritation if the patient lies down too soon. The other choices are not relevant to the specific instructions needed for alendronate.
A nurse is educating a parent of a 6-month-old infant about car seat safety. Which statement from the parent indicates a correct understanding of the teaching?,Which statement indicates correct understanding of car seat safety?
- A. Our car seat is an infant model and is anchored in the car.
- B. The car seat is rear-facing in the front passenger seat.
- C. I can fit my hand between the baby and the car seat harness.
- D. Our car seat is front-facing in the back seat.
Correct Answer: A
Rationale: The correct answer is A because anchoring the infant car seat in the car is crucial for safety. This ensures the seat is securely installed and minimizes the risk of injury during a collision. Choice B is incorrect as rear-facing car seats should never be placed in the front passenger seat due to the presence of airbags, which can be dangerous for infants. Choice C is incorrect because the harness should be snug against the infant's body without any slack, and being able to fit a hand between the harness and the baby indicates it is too loose. Choice D is incorrect as infants should be in rear-facing seats until at least 2 years old for optimal safety.
A nurse is calculating the total fluid intake for a patient over a 4-hour period. The patient consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. How many mL of intake should the nurse record on the patient's chart? How many mL of fluid intake should the nurse record?
Correct Answer: 1160
Rationale: The correct answer is 1160 mL. To calculate this, first convert all measurements to mL: 1 cup = 240 mL, 1 oz = 30 mL.
Coffee (240 mL), orange juice (120 mL), water (90 mL), flavored gelatin (240 mL), tea (240 mL), broth (150 mL), water (90 mL).
Adding these up: 240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL.
Therefore, the nurse should record 1160 mL on the patient's chart.
Other choices are incorrect because they do not calculate the total accurately or convert all measurements to mL.