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 A
Explanation
Choice A rationale:
Dakin’s solution is used for chemical debridement, which involves the use of a chemical, such as Dakin’s solution, to break down and remove dead tissue.
Choice B rationale:
Primary intention is a term used to describe the healing of a clean wound without tissue loss. Dakin’s solution does not directly contribute to this process.
Choice C rationale:
While Dakin’s solution can aid in the healing process by preventing and treating infections, it does not directly cause healing.
Choice D rationale:
Phagocytosis is a process carried out by certain cells in the body to engulf and destroy pathogens or debris. Dakin’s solution does not perform this function.
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