The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.
The nurse's most beneficial intervention would be to:
Moisten it with povidone iodine.
Pull it off using slow, steady pressure.
Add normal saline to loosen it.
Leave it in place and cover it with new, wet dressings.
The Correct Answer is C
Choice A rationale:
Moistening the dressing with povidone iodine could cause irritation and is not the best method for removing a dressing stuck to the wound bed.
Choice B rationale:
Pulling off the dressing using slow, steady pressure could cause trauma to the wound bed and increase pain.
Choice C rationale:
Adding normal saline to loosen the dressing minimizes trauma to the wound bed and reduces pain during dressing removal.
Choice D rationale:
Leaving the old dressing in place and covering it with new, wet dressings could lead to infection and is not the best method for managing a dressing stuck to the wound bed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Full thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not stage 1.
Choice B rationale:
Full thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not stage 1.
Choice C rationale:
Stage 1 pressure injuries are characterized by intact skin with localized erythema.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not stage 1.
Correct Answer is B
Explanation
Choice A rationale:
Numbing the area treated is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.
Choice B rationale:
Dilating the blood vessels is the correct answer. Moist heat therapy works by increasing the temperature of the skin/soft tissue, which leads to vasodilation and increased blood flow to the treated area.
Choice C rationale:
Drawing fluid to the site of application is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area.
Choice D rationale:
Constricting the blood vessels is not a physiological effect of moist heat. Moist heat primarily works by increasing blood flow to the treated area through vasodilation.
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