A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is 4 cm in length, 3 cm in width, and 2 cm in depth. The wound bed is 80% granulation tissue and 20% slough. Which type of dressing should the nurse use for this wound?

Hydrocolloid

Hydrogel

Alginate

Transparent film

Answer and Explanation

The Correct Answer is C

Correct answer: C) Alginate

Rationale: Alginate is a type of dressing that is derived from seaweed and forms a gel-like substance when in contact with wound exudate. It is highly absorbent and can handle moderate to large amounts of drainage. It also provides a moist wound environment and supports autolytic debridement of slough and eschar. It is suitable for wounds with depth, such as stage 3 or 4 pressure ulcers.

Incorrect options:

A) Hydrocolloid - This is a type of dressing that has an adhesive outer layer and an inner layer that forms a gel when in contact with wound fluid. It is occlusive and waterproof and provides a moist wound environment. It is suitable for wounds with minimal to moderate drainage, such as stage 2 pressure ulcers or partial-thickness burns. It is not recommended for wounds with depth, as it may cause maceration of the surrounding skin.

B) Hydrogel - This is a type of dressing that consists of water or glycerin-based gels that are available in sheets, gauze, or impregnated into other types of dressings. It provides moisture to dry wounds and facilitates autolytic debridement. It is suitable for wounds with minimal drainage, such as stage 2 pressure ulcers or partial-thickness burns. It is not recommended for wounds with moderate to large amounts of drainage, as it may cause maceration or leakage.

D) Transparent film - This is a type of dressing that consists of a thin sheet of polyurethane with an adhesive coating that allows the exchange of oxygen and moisture vapor but not bacteria or water. It provides a moist wound environment and facilitates autolytic debridement. It is suitable for wounds with minimal drainage, such as stage 1 pressure ulcers or superficial abrasions. It is not recommended for wounds with depth or moderate to large amounts of drainage, as it may cause maceration or leakage.

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Correct Answer is B

Explanation

Correct answer: B) Instruct the client to splint the incision when coughing

Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.

Incorrect options:

A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.

C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.

D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.

A. Soaking the old dressing with sterile saline before removing it B. Applying antibiotic ointment to the new dressing before placing it on the wound C. Moistening the new dressing with sterile water before wringing it out and applying it to the wound D. Covering the new dressing with an occlusive secondary dressing to prevent evaporation

Correct Answer is C

Explanation

Correct answer: C) Moistening the new dressing with sterile water before wringing it out and applying it to the wound

Rationale: Wet-to-dry dressings are used for mechanical debridement of necrotic tissue from chronic wounds. The new dressing should be moistened with sterile water (not saline, as saline can cause sodium crystals to form on the wound bed and impair healing), wrung out to remove excess moisture (to prevent maceration of surrounding skin), and loosely packed into the wound (to allow contact with necrotic tissue). The old dressing should be removed dry (not soaked, as soaking can rehydrate necrotic tissue and reduce debridement).

Incorrect options:

A) Soaking the old dressing with sterile saline before removing it - This can rehydrate necrotic tissue and reduce debridement.

B) Applying antibiotic ointment to the new dressing before placing it on the wound - This can interfere with debridement and increase the risk of infection and resistance.

D) Covering the new dressing with an occlusive secondary dressing to prevent evaporation - This can create a moist environment that promotes bacterial growth and infection.

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A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is 4 cm in length, 3 cm in width, and 2 cm in depth. The wound bed is 80% granulation tissue and 20% slough. Which type of dressing should the nurse use for this wound?

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A client has a stage 3 pressure ulcer on the left trochanter with moderate serosanguineous drainage. The wound is 4 cm in length, 3 cm in width, and 2 cm in depth. The wound bed is 80% granulation tissue and 20% slough. Which type of dressing should the nurse use for this wound?

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