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 C

Explanation

Choice A rationale:

Stage 1 pressure ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice B rationale:

Stage 3 pressure ulcers involve full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice C rationale:

Stage 2 pressure ulcers involve partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale:

Stage 4 pressure ulcers involve full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed.

A. sharp debridement. B. chemical debridement. C. enzymatic debridement. D. autolytic debridement.

Correct Answer is D

Explanation

Choice A rationale:

Sharp debridement involves the use of a sharp instrument or heat to remove dead tissue, which is not achieved with a hydrocolloid dressing.

Choice B rationale:

Chemical debridement involves the use of chemicals to remove dead tissue, which is not the function of a hydrocolloid dressing.

Choice C rationale:

Enzymatic debridement involves the use of enzymes to soften and remove dead tissue, which is not the function of a hydrocolloid dressing.

Choice D rationale:

Autolytic debridement uses the body’s own enzymes and moisture to soften and remove dead tissue. A hydrocolloid dressing helps maintain a moist wound environment, promoting autolytic debridement.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 48-year-old female patient with DM, HTN, and limited mobility.Upon assessment, she notes that there is a pink, viable wound bed, with partial-thickness skin loss.

Correct Answer is C

Explanation

Which type of debridement is a hydrocolloid dressing used for?

Correct Answer is D

Explanation

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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: