a provider has ordered a wound culture for a client with a non healing wound what is the nurses first action

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. A provider has ordered a wound culture for a client with a non-healing wound. What is the nurse's first action?

A. Label the specimen tube
B. Put on non-sterile gloves
C. Gently remove the soiled dressings
D. Irrigate the wound

Correct answer: B

Rationale:

2. A post-operative client with a sutured abdominal incision felt a sharp abdominal pain after having a bowel movement. Upon inspection, the nurse notices bowel protruding from the incision site. What does the nurse tell the physician about the event?

A. The client's incision site has eviscerated
B. The client's incision site has lacerated
C. The client's incisional site is approximated
D. The client's incisional site has dehisced after.

Correct answer: A

Rationale:

3. What is the condition called when the client's pupils are different sizes and have been this way since childhood?

A. Exophthalmos
B. Anisocoria
C. Strabismus
D. Scleral edema

Correct answer: B

Rationale: Anisocoria is the correct answer. Anisocoria is the condition of having pupils of different sizes. Exophthalmos refers to abnormal protrusion of the eyeball, not pupil size difference. Strabismus is a condition where the eyes are not properly aligned with each other. Scleral edema is swelling of the sclera, the white part of the eye, and not related to differing pupil sizes.

4. What lifestyle habits positively affect skin integrity?

A. Regular exercise
B. Tattoos
C. Smoking
D. Tanning

Correct answer: A

Rationale:

5. What is one of the earliest signs of fat embolism syndrome?

A. Paresthesia
B. Severe pain in the affected limb unrelieved by medication
C. Edema
D. Hypoxemia

Correct answer: D

Rationale: Hypoxemia is one of the earliest signs of fat embolism syndrome. In fat embolism syndrome, fat globules enter the bloodstream and can obstruct blood flow in the lungs, leading to hypoxemia. Paresthesia, severe pain unrelieved by medication, and edema are not typically among the earliest signs of fat embolism syndrome.