A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.
Which of the following techniques should the nurse use when performing this dressing change?
Remove the tape by pulling from the center of the dressing
Wear sterile gloves to remove the dressing
Clean the wound from the center to the outer edges
Moisten the dressing before removal
The Correct Answer is C
When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.
The other options listed are not recommended for this specific procedure:
When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.
While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.
In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A. Create an opening on the skin barrier that is 1.27 cm (0.5 in) larger than the client's stoma.The opening on the skin barrier should be cut to fit closely around the stoma, approximately 0.3-0.6 cm (1/8 to 1/4 inch) larger than the stoma size. A larger opening (like 0.5 inches) could expose too much surrounding skin, increasing the risk of skin irritation from contact with the stoma's effluent.
B. Use a moisturizing soap to clean the skin around the client's stoma.Moisturizing soaps should be avoided because they can leave a residue on the skin, which may interfere with the adhesion of the ostomy appliance. The skin around the stoma should be cleaned with mild soap and water, or water alone, and then dried thoroughly before applying the new appliance.
C. Empty the client's ostomy pouch before removing the skin barrier.Emptying the ostomy pouch before removing the skin barrier is a practical step to reduce spillage of stool during the appliance change, making the process cleaner and easier to manage. It also minimizes the risk of contamination of the surrounding area or wound.
D. Change the client's ostomy appliance 1 hour after breakfast.Ostomy appliances are best changed when the bowel is least active, which is usually before a meal or several hours after eating. Changing the appliance shortly after a meal, such as 1 hour after breakfast, may result in more stoma output, making it harder to manage the appliance change.
Correct Answer is D
Explanation
Having the baby latch on to both the nipple and areola during breastfeeding is essential for effective milk transfer and optimal breastfeeding. The baby should take in a good portion of the areola along with the nipple to ensure a proper latch and a comfortable feeding experience for both the mother and the baby. This allows the baby to obtain enough milk and stimulates milk production in the mother.
Let's briefly discuss the other statements:
A- "My baby should breastfeed 5 to 10 minutes on each breast": The duration of breastfeeding can vary from baby to baby, but it is generally recommended to allow the baby to breastfeed until they are satisfied and have emptied one breast before switching to the other breast. This ensures that the baby receives both the foremilk and the hindmilk, which are important for adequate nutrition.
B- "I should not wake my baby during the night to breastfeed": In the early days after birth, it is important to establish frequent and regular breastfeeding to support milk production and ensure the baby receives enough nourishment. Newborns typically need to breastfeed at least 8 to 12 times in 24 hours, including during the night. If the baby is sleeping for a long period, it may be necessary to wake them for feeding to ensure proper nutrition and hydration.
C- "I should keep my baby on a strict feeding schedule": Breastfeeding should be based on the baby's cues and demand rather than a strict schedule. Newborns should be breastfed whenever they show hunger signs, such as rooting, sucking motions, or increased alertness. This helps establish a good milk supply and allows the baby to feed according to their individual needs.
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