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:

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.

A. BMI of 20. B. Peripheral neuropathy. C. Immobility. D. Hypoperfusion. E. Prealbumin level of 16 mg/dL.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.

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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 places Dakin solution in a wound to accomplish chemical:

Correct Answer is A

Explanation

A nurse is collecting data on a client.Which of the following findings increase the client's risk of a pressure injury?

Correct Answer is ["B","C","D","E"]

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: