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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Using the overbed trapeze helps the client strengthen their upper body and improve mobility by allowing them to independently move and reposition themselves in bed. This promotes independence in activities of daily living and reduces reliance on nursing assistance.

Cautioning the client to avoid a prone position while in bed is important for preventing pressure ulcers and maintaining proper positioning, but it does not specifically promote independence and mobility.

Keeping a loose, absorbent dressing over the surgical site is important for wound care and infection prevention, but it does not directly promote mobility or independence. Maintaining abduction of the client's residual limb with a pillow is important to prevent contractures, but it does not directly promote mobility or independence.

A. Limit the use of familiar objects. B. Make a schedule of daily tasks. C. Ask questions that require more than one answer. D. Have several family members visit daily.

Correct Answer is B

Explanation

B. Make a schedule for daily task.

Creating a schedule of daily tasks can provide structure and routine for individuals with Alzheimer's disease. This helps reduce confusion and frustration by providing a sense of familiarity and predictability. The schedule should be displayed in a visible location and include activities such as meals, personal care, medication administration, and any recreational or therapeutic activities. Following the schedule can help the client feel more oriented and decrease their frustration levels.

Limiting the use of familiar objects in (option A) should not be included because it may further increase frustration and disorientation. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease.

Asking questions that require more than one answer in (option C) should not be included because it can be overwhelming and confusing for someone with Alzheimer's disease. It is best to ask simple, straightforward questions to facilitate communication and comprehension.

Having several family members visit daily in (option D) should not be included because it may cause agitation and overstimulation for the client. It is important to maintain a calm and predictable environment, limiting the number of visitors and ensuring they are familiar to the client.
Therefore, the most appropriate intervention for the nurse to include is making a schedule of daily tasks (option B).

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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?

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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?