A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

Change the dressing when it is saturated.

Assess the wound bed once a day.

Contact the provider when the dressing leaks.

Change the dressing every 6 hours.

Answer and Explanation

The Correct Answer is A

A. Change the dressing when it is saturated:

This intervention is the most appropriate for managing a deep wound with a wet to-damp dressing. Wet to-damp dressings are designed to maintain a moist environment conducive to wound healing. Changing the dressing when it becomes saturated with wound exudate helps prevent excessive moisture accumulation, which can lead to skin maceration and potential infection. It ensures that the wound bed remains in an optimal healing environment and reduces the risk of complications.

B. Assess the wound bed once a day:

Assessing the wound bed is an essential part of wound care, as it allows the nurse to monitor healing progress, assess for signs of infection, and evaluate the effectiveness of the chosen dressing. However, the frequency of wound bed assessment may vary depending on the specific patient's needs and the type of dressing being used. While daily assessment is generally recommended, it does not directly dictate the timing of dressing changes for wet to-damp dressings, which are primarily changed based on saturation levels.

C. Contact the provider when the dressing leaks:

Contacting the provider when the dressing leaks or when there are concerns or complications is an important step in patient care. Leaking dressings can indicate issues with the dressing application, excessive wound exudate, or potential complications such as infection. It's crucial to inform the provider promptly so that appropriate interventions can be implemented, but this instruction is more reactive and does not specifically address the timing of dressing changes.

D. Change the dressing every 6 hours:

Changing the dressing every 6 hours is not typically recommended for wet to-damp dressings unless specifically indicated based on the patient's condition and the amount of wound exudate. Frequent dressing changes can disrupt the healing process, cause unnecessary trauma to the wound bed, and increase the risk of infection. Dressing change frequency should be based on the assessment of wound exudate and the dressing's ability to maintain a moist environment.

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Correct Answer is A

Explanation

A. There is no redness, warmth, or drainage at the insertion site.

This assessment is crucial for evaluating the status of the abdominal drain site. The absence of redness, warmth, or drainage suggests that the insertion site is healing well without signs of infection or inflammation. It indicates that the drain is functioning properly and that there are no immediate complications related to the drain insertion. This assessment directly addresses the goals related to monitoring the drain site for signs of infection or dysfunction.

B. Drainage from the surgical site is 30 mL less than yesterday.

Monitoring the drainage output from the surgical site is important to assess for changes in drainage patterns. A decrease in drainage volume may indicate reduced fluid accumulation at the surgical site, potentially reflecting improved healing and decreased need for drainage. However, while this assessment is valuable, it is not as directly related to assessing the status of the drain itself or evaluating complications at the insertion site as option A.

C. The patient reports adequate pain control with medications.

Pain control is an essential aspect of postoperative care, but it is not specifically related to assessing the functionality or complications of the abdominal drain. While pain management is important for patient comfort and recovery, it does not directly address the goals related to monitoring the drain site for signs of infection, leakage, or other complications.

D. Urine is clear yellow, and urine output is greater than 40 mL/hr.

While monitoring urine output and characteristics is important for assessing renal function and hydration status, it is not directly related to assessing the abdominal drain or its complications. Clear yellow urine and adequate urine output are generally positive indicators but do not provide specific information about the functionality or status of the drain.

A. Assess the patient’s respiratory rate, rhythm, depth B. Call the healthcare provider C. Document findings and monitor the patient D. Measure the patient’s pulse and blood pressure

Correct Answer is A

Explanation

A. Assess the patient’s respiratory rate, rhythm, depth:

This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.

B. Call the healthcare provider:

While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.

C. Document findings and monitor the patient:

Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.

D. Measure the patient’s pulse and blood pressure:

While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.

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A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

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A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?