Question

the nurse cares for a client with an open, draining wound on the lower left leg. the client has a white blood cell count (wbc) of 16,000/mm³ (16 × 10⁹/l). which intervention does the nurse include in the clients plan of care?

1. place the client on bleeding precautions.
2. administer an antibiotic by intramuscular injection.
3. obtain a culture of the wound and send to the laboratory.
4. limit visitors and place the client on contact precautions.

Explanation:

• Option 1: Bleeding precautions are for clients with bleeding risks (e.g., low platelets), not elevated WBC or open wounds. So this is incorrect.
• Option 2: Administering an antibiotic without knowing the causative organism (via culture) is not appropriate initial care. So this is incorrect.
• Option 3: A client with an open, draining wound and elevated WBC (indicating possible infection) should have a wound culture to identify the pathogen, guiding treatment. This is the correct intervention.
• Option 4: Contact precautions and limiting visitors are not the first priority; identifying the infection source via culture is more important. So this is incorrect.

Answer:

1. Obtain a culture of the wound and send to the laboratory.