The nurse is performing a routine dressing change for a patient with a stage 3 pressure injury that is red with significant granulation.
The wound has a gauze dressing covering the area. Which action should the nurse implement?

Choice A rationale:

Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.

While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.

Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.

Choice C rationale:

Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.

It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:

Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.

Choice B rationale:

Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.

Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.

Are comfortable for the patient and can be left in place for several days.

Here are the steps to calculate the IV flow rate:

Step 1: Calculate the volume to be infused per minute.

75 mL ÷ 30 minutes = 2.5 mL/minute

Step 2: Multiply the volume per minute by the drop factor to determine the drops per minute.

2.5 mL/minute × 15 gtt/mL = 37.5 gtt/minute

Step 3: Round the answer to the nearest whole number. The nurse should regulate the IV to deliver 38 gtt/minute.