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 D
Explanation
Choice A rationale:
Hydrocolloid dressings do not keep the wound dry; they maintain a moist environment.
Choice B rationale:
These dressings do not have antimicrobial properties.
Choice C rationale:
While these dressings can be left in place for several days, it is not their major purpose.
Choice D rationale:
Hydrocolloid dressings occlude air and promote autolytic debridement of necrotic tissue.
Correct Answer is D
Explanation
Choice A rationale:
Karaya paste is used for ostomy care, not for dressing changes.
Choice B rationale:
Paper tape might not provide the necessary adhesion for frequent dressing changes.
Choice C rationale:
Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.
Choice D rationale:
Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.
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