A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

Change the dressing when it is saturated.

Assess the wound bed once a day.

Contact the provider when the dressing leaks.

Change the dressing every 6 hours.

Answer and Explanation

The Correct Answer is A

A. Change the dressing when it is saturated:

This intervention is the most appropriate for managing a deep wound with a wet to-damp dressing. Wet to-damp dressings are designed to maintain a moist environment conducive to wound healing. Changing the dressing when it becomes saturated with wound exudate helps prevent excessive moisture accumulation, which can lead to skin maceration and potential infection. It ensures that the wound bed remains in an optimal healing environment and reduces the risk of complications.

B. Assess the wound bed once a day:

Assessing the wound bed is an essential part of wound care, as it allows the nurse to monitor healing progress, assess for signs of infection, and evaluate the effectiveness of the chosen dressing. However, the frequency of wound bed assessment may vary depending on the specific patient's needs and the type of dressing being used. While daily assessment is generally recommended, it does not directly dictate the timing of dressing changes for wet to-damp dressings, which are primarily changed based on saturation levels.

C. Contact the provider when the dressing leaks:

Contacting the provider when the dressing leaks or when there are concerns or complications is an important step in patient care. Leaking dressings can indicate issues with the dressing application, excessive wound exudate, or potential complications such as infection. It's crucial to inform the provider promptly so that appropriate interventions can be implemented, but this instruction is more reactive and does not specifically address the timing of dressing changes.

D. Change the dressing every 6 hours:

Changing the dressing every 6 hours is not typically recommended for wet to-damp dressings unless specifically indicated based on the patient's condition and the amount of wound exudate. Frequent dressing changes can disrupt the healing process, cause unnecessary trauma to the wound bed, and increase the risk of infection. Dressing change frequency should be based on the assessment of wound exudate and the dressing's ability to maintain a moist environment.

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Correct Answer is D

Explanation

A. Provide a heart-healthy low-potassium diet:

While a heart-healthy low-potassium diet is essential for managing chronic hyperkalemia and preventing future occurrences, it is not the first intervention to implement in a patient with a serum potassium level of 7.5 mEq/L and exhibiting cardiovascular changes. The effects of dietary changes on serum potassium levels are gradual and may take days to have a significant impact. In an acute situation like this, immediate interventions are needed to rapidly lower potassium levels and address the associated cardiovascular risks.

B. Prepare to administer sodium polystyrene sulfate 15g by mouth:

Sodium polystyrene sulfate is a medication used to exchange sodium for potassium in the gastrointestinal tract, effectively lowering serum potassium levels over hours to days. While it is a valid treatment for hyperkalemia, its onset of action is not immediate enough to address the urgent cardiovascular changes seen in severe hyperkalemia. Therefore, it is not the first-line intervention in this scenario.

C. Prepare the patient for hemodialysis treatment:

Hemodialysis is an effective method for rapidly lowering serum potassium levels in cases of severe hyperkalemia. However, it is a more invasive and time-consuming procedure that requires preparation, including vascular access and dialysis setup. It is typically reserved for situations where other interventions have failed or in patients with severe or refractory hyperkalemia. In the context of this scenario, where the patient has a serum potassium level of 7.5 mEq/L and is exhibiting cardiovascular changes, hemodialysis may be considered if initial interventions are not successful, but it is not the first action to implement.

A. Increased pulse rate B. Decreased blood pressure C. Skeletal muscle weakness D. Warm and pink skin E. Distended neck veins

Correct Answer is ["E"]

Explanation

A. Increased pulse rate:

This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.

B. Decreased blood pressure:

Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.

C. Skeletal muscle weakness:

Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.

D. Warm and pink skin:

Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.

E. Distended neck veins:

Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.

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A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for a patient who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which should the nurse implement first?

Correct Answer is D

Explanation

A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

Correct Answer is ["E"]

Explanation

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