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 D

Explanation

The correct answer is Choice D.

Choice A rationale: Leaving nonbleeding wounds open to air increases the risk of infection and delayed healing. Wounds need a moist environment to promote cell migration and collagen synthesis, essential for the initial inflammatory phase of healing.

Choice B rationale: Corticosteroids suppress the immune response and inflammation, which can delay wound healing. They inhibit leukocyte migration and fibroblast proliferation, which are crucial during the initial stage of the healing process.

Choice C rationale: Mechanical debridement is typically used for chronic wounds with necrotic tissue. In the initial stage of wound healing, it is not necessary and could damage newly formed tissue, delaying the healing process.

Choice D rationale: Oxygen therapy at 2L/min via nasal cannula enhances tissue oxygenation, promoting cellular activities such as collagen synthesis, angiogenesis, and leukocyte function, which are critical during the initial inflammatory phase of wound healing.

A. Strengthening the wall of the wound. B. Drawing the wound edges together by negative pressure. C. Making an air occlusive cover for the wound. D. Interrupting the proliferation of bacteria in the wound.

Correct Answer is B

Explanation

Choice A rationale:

Strengthening the wall of the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice B rationale:

Drawing the wound edges together by negative pressure is the correct answer. Vacuum-assisted closure, also known as negative pressure wound therapy, works by applying negative pressure to the wound, which helps to draw the edges of the wound together and promote healing.

Choice C rationale:

Making an air occlusive cover for the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

Choice D rationale:

Interrupting the proliferation of bacteria in the wound is not the primary function of vacuum-assisted closure. The main function is to promote wound healing by applying negative pressure.

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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

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Correct Answer is D

Explanation

The nurse clarifies that a vacuum-assisted closure supports healing of a wound by:

Correct Answer is B

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: