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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.

A. Perform gastric lavage with activated charcoal. B. Begin hemodialysis within the next 24 hr. C. Prepare to give oral N-acetylcysteine. D. Send the child home on increased fluid intake.

Correct Answer is C

Explanation

A. Perform gastric lavage with activated charcoal. Activated charcoal is most effective if given within 1 hour of ingestion. Since the ingestion occurred 4 hours ago, activated charcoal would not be beneficial.
B. Begin hemodialysis within the next 24 hr. Hemodialysis is only used in severe cases of acetaminophen toxicity with liver failure, which is not indicated at this stage.
C. Prepare to give oral N-acetylcysteine. N-acetylcysteine (NAC) is the antidote for acetaminophen overdose and should be administered as soon as possible within 8 to 10 hours after ingestion to prevent liver damage.
D. Send the child home on increased fluid intake. Acetaminophen overdose can cause severe liver toxicity, so treatment in a medical setting is required, not just increased fluids at home.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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