A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?

Soaking the old dressing with sterile saline before removing it

Applying antibiotic ointment to the new dressing before placing it on the wound

Moistening the new dressing with sterile water before wringing it out and applying it to the wound

Covering the new dressing with an occlusive secondary dressing to prevent evaporation

Answer and Explanation

The Correct Answer is C

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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Correct Answer is A

Explanation

Correct answer: A) Hydrocolloid

Rationale: Hydrocolloid dressings are occlusive and adhesive, forming a gel-like substance over the wound bed that maintains a moist environment and facilitates autolytic debridement. They are suitable for stage 3 pressure ulcers, as they protect the wound from contamination and reduce pain and trauma during dressing changes.

Incorrect options:

B) Transparent film - This type of dressing is semi-permeable and allows oxygen exchange, but does not absorb exudate or provide cushioning. It is suitable for stage 1 pressure ulcers, as it protects the skin from friction and moisture.

C) Calcium alginate - This type of dressing is highly absorbent and forms a gel-like substance when in contact with wound exudate. It is suitable for stage 4 pressure ulcers with heavy drainage, as it fills the dead space and promotes hemostasis.

D) Gauze - This type of dressing is inexpensive and readily available, but it can adhere to the wound bed and cause pain and bleeding during removal. It is suitable for stage 4 pressure ulcers with minimal drainage, as it provides mechanical debridement.

A. Eschar B. Slough C. Fibrin D. Exudate

Correct Answer is A

Explanation

Correct answer: A) Eschar

Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.

Incorrect options:

B) Slough - This is dead tissue that is yellow, tan, gray, green, or brown and has a moist, stringy, or mucinous appearance. It may be loosely attached or firmly adherent to the wound bed. It should be removed to promote wound healing.

C) Fibrin - This is a protein involved in blood clotting that forms a mesh-like structure to seal the wound and stop bleeding. It may appear as a yellowish-white film on the wound surface. It should not be confused with slough or pus.

D) Exudate - This is fluid that leaks out of blood vessels into the surrounding tissues due to inflammation or injury. It may have different characteristics depending on the type and stage of the wound. It should be managed to maintain a moist but not wet wound environment.

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A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?

Nursing Test Bank

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Correct Answer is A

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