A nurse is applying a dressing to a wound that has moderate to heavy exudate. Which of the following types of dressing would be most appropriate for this wound?

Correct answer: C) Ensure that the dressing is sealed and airtight around the wound.

Rationale: Negative pressure wound therapy (NPWT) is a device that applies

subatmospheric pressure to the wound bed, which promotes granulation tissue formation, removes excess fluid and debris, and reduces edema and bacterial colonization. The nurse should ensure that the dressing is sealed and airtight around the wound to maintain negative pressure and prevent air leaks.

Incorrect options:

A) Change the dressing every 12 hours or as needed. - This is not recommended for NPWT, as frequent dressing changes can disrupt wound healing and increase the risk of infection. The nurse should change the dressing every 48 to 72 hours or as prescribed by the provider.

B) Irrigate the wound with normal saline before applying the dressing. - This is not recommended for NPWT, as irrigation can introduce bacteria into the wound and interfere with negative pressure. The nurse should clean the wound with normal saline or sterile water and pat it dry gently before applying the dressing.

D) Clamp the tubing when ambulating or repositioning the client. - This is not recommended for NPWT, as clamping can interrupt negative pressure and cause tissue damage. The nurse should secure the tubing to prevent kinking or dislodgment and keep the device below the level of the wound when ambulating or repositioning the client.

Answer: A.

Slough is dead tissue that is shed from the surface of the wound. It may be white, yellow, green, or brown in color and may have a soft, moist, or dry texture. It should be removed to promote wound healing.

B. Eschar is dead tissue that adheres to the surface of the wound. It may be black, brown, or tan in color and may have a hard, dry, or leathery texture. It may act as a natural barrier to infection in some cases, but it may also impair wound healing and circulation in others.

C. Granulation tissue is new tissue that forms in the base of the wound during healing. It is red or pink in color and has a shiny, moist, granular appearance. It indicates healthy wound healing and should be protected from trauma or infection.

D. Epithelial tissue is new tissue that forms over the granulation tissue during healing. It is pink or pale in color and has a thin, smooth, translucent appearance. It indicates the final stage of wound healing and should be moisturized and protected from sun exposure.