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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Correct Answer is B
Explanation
A. "I will lay my baby on their side to sleep for naps." The supine (on the back) position is the safest for sleep to reduce the risk of SUIDS.
B. "I will dress my baby in lightweight clothing to sleep." Overheating is a risk factor for SUIDS. Lightweight clothing helps prevent overheating and promotes safe sleep.
C. "I will have my baby sleep next to me in bed during the night." Bed-sharing increases the risk of suffocation and SUIDS. Room-sharing with a separate sleep surface is recommended.
D. "I will move my baby's stuffed animal to the corner of their crib while they sleep." Soft objects, including stuffed animals and blankets, should not be in the crib at all to reduce the risk of suffocation.
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