A nurse is performing a dressing change for a child and notices that the gauze dressing is adhering to the wound bed. Which of the following actions should the nurse take?
Apply firm pressure to the wound base while removing the gauze dressing.
Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing.
Continue to remove the gauze dressing by pulling it parallel to the skin.
Saturate the gauze dressing with sterile saline solution prior to removing it.
The Correct Answer is D
A. "Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. "Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. "Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. "Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A","dropdown-group-3":"B"}
Explanation
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Correct Answer is C
Explanation
A. "Hypertension" Epidural anesthesia typically causes hypotension, not hypertension, due to vasodilation and decreased sympathetic nervous system activity.
B. "Mild sedation" While some systemic absorption of anesthetics may occur, epidural anesthesia primarily affects sensory and motor function rather than causing significant sedation.
C. "Urinary retention" Epidural anesthesia can inhibit bladder sensation and detrusor muscle function, leading to urinary retention. The nurse should monitor urine output and assess for bladder distention.
D. "Respiratory depression" While respiratory depression can occur with high doses of opioids administered through an epidural, it is not a common expected effect of epidural anesthesia alone.
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