While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?
Leave it in place and cover it with new, wet dressings.
Moisten it with povidone-iodine.
Add normal saline to loosen it.
Pull it off using slow, steady pressure.
The Correct Answer is C
Choice A rationale
Leaving the old dressing in place and simply covering it with new wet dressings would not address the issue of the dressing being adhered to the wound bed, which could lead to further tissue damage when it is eventually removed.
Choice B rationale
Povidone-iodine is an antiseptic and not typically used to moisten dressings that are stuck to a wound bed, as it may irritate the wound and delay healing.
Choice C rationale
Adding normal saline is the gentlest method to loosen a dressing that is stuck to a wound bed. It helps to rehydrate the dressing and the wound, making it easier to remove without causing additional trauma to the healing tissue.
Choice D rationale
Pulling off the dressing using slow, steady pressure could cause damage to the new tissue forming in the wound bed and should be avoided unless all other methods have failed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A contusion, commonly known as a bruise, is characterized by bleeding under the skin, causing discoloration and swelling. It does not involve a break in the skin and therefore does not match the description of the wound with torn skin tissue.
Choice B rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse discovered torn skin tissue, this type of wound is consistent with the client’s injury described in the scenario.
Choice C rationale
An abrasion is a wound caused by superficial damage to the skin, usually no deeper than the epidermis. It is typically caused by a scrape against a rough surface and is not associated with torn skin tissue.
Choice D rationale
A puncture is a small hole caused by a long, pointed object, such as a nail or needle. This type of wound usually does not result in torn skin tissue but rather a deeper, more narrow penetration.
Correct Answer is A
Explanation
Choice A rationale
The nurse’s first priority should always be to assess the patient’s condition. In the context of NPWT, this means checking for any complaints or problems in the wound area. This assessment helps to ensure that the NPWT is not causing additional issues and that the wound is healing as expected.
Choice B rationale
While it is important to check the settings on the NPWT unit to ensure it is functioning correctly, this is not the first priority. The patient’s well-being and response to treatment take precedence over equipment checks.
Choice C rationale
Documentation is a critical part of patient care, but it comes after patient assessment and any necessary interventions. It serves to record the patient’s status and the care provided but is not the immediate priority.
Choice D rationale
Observing the dressing area is part of the overall assessment of the patient and the effectiveness of the NPWT. However, it is not the first action to take. The nurse must first assess the patient for any discomfort or complications before focusing on the dressing itself.
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