The nurse needs to send a specimen for a wound culture. What should the nurse do prior to obtaining the specimen?

Correct Answer: B

Rationale: The correct answer is B: Flush the wound bed with sterile saline. Prior to obtaining a wound culture specimen, flushing the wound bed with sterile saline helps remove debris and contaminants. This step ensures that the specimen collected is not contaminated, providing accurate culture results. Applying clean gloves (A) is important but does not directly impact the quality of the specimen. Cleansing the wound with antimicrobial solution (C) may interfere with the culture results by killing bacteria present. Keeping the wound open to air for several minutes (D) does not contribute to obtaining a clean specimen.

Correct Answer: D

Rationale: The correct answer is D: Suspected tissue injury. This classification is appropriate because the skin presentation described does not meet the specific criteria for Stage III or IV ulcers, which involve skin breakdown and tissue damage extending into deeper layers. The term "unstageable" is used when the wound bed is obscured, usually by eschar or slough, making it impossible to determine the depth of tissue damage. In this case, the presence of a blood-filled blister and pain suggests a superficial injury without visible tissue loss, indicating a suspected tissue injury rather than a defined stage of ulcer development. This classification allows for further assessment and monitoring to determine the extent of tissue damage.

Correct Answer: A

Rationale: The correct answer is A: keratin. Keratin is a fibrous structural protein that is the main component of hair, epidermis, and nails. It provides strength, durability, and protection to these structures. Vitamin D (choice B) is important for bone health and is not a component of hair, epidermis, or nails. Adipose tissue (choice C) is fat tissue and is not a component of these structures. Collagen (choice D) is a different type of protein found in connective tissues such as tendons and ligaments, not in hair, epidermis, or nails.

Correct Answer: B

Rationale: The correct answer is B because applying an emollient after a bath or shower helps seal in moisture and prevents evaporation of water from the hydrated epidermis, promoting hydration and maintaining skin integrity. This is crucial for managing pruritus. Summary: A: While emollients can help reduce skin irritation, the main purpose of applying it after a bath is to prevent water loss. C: Emollients do not enhance skin absorption of medication. D: Cooling the skin is not the primary reason for applying emollients after a bath.

Correct Answer: A

Rationale: The correct answer is A: Partial-thickness skin loss of the dermis. This aligns with the definition of a stage II pressure ulcer, which involves partial-thickness skin loss involving the epidermis and/or dermis. This stage typically presents as a shallow open ulcer with a red-pink wound bed. Choice B (Full-thickness skin loss) is incorrect as it corresponds to a stage III pressure ulcer where there is full-thickness tissue loss. Choice C (Blistering without skin loss) is incorrect as it describes a stage II pressure injury, not a pressure ulcer. Choice D (Intact skin with redness) is incorrect as it signifies a stage I pressure ulcer, where there is non-blanchable erythema of intact skin. Therefore, the nurse would expect to see partial-thickness skin loss of the dermis in the sacral area of the client with a stage II pressure ulcer.