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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

A. restlessness, rising pulse, and falling blood pressure. B. lethargy, falling pulse, and rising blood pressure. C. headache, rising pulse, and falling blood pressure. D. restlessness, falling pulse, and rising blood pressure.

Correct Answer is A

Explanation

Choice A rationale:

Restlessness, rising pulse, and falling blood pressure are classic signs of shock, which can occur with internal hemorrhage.

Choice B rationale:

Lethargy, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

Choice C rationale:

Headache, rising pulse, and falling blood pressure could be signs of many conditions, but they are not specific to internal hemorrhage.

Choice D rationale:

Restlessness, falling pulse, and rising blood pressure are not typically associated with internal hemorrhage.

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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:

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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: