A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?

Soaking the old dressing with sterile saline before removing it

Applying antibiotic ointment to the new dressing before placing it on the wound

Moistening the new dressing with sterile water before wringing it out and applying it to the wound

Covering the new dressing with an occlusive secondary dressing to prevent evaporation

Answer and Explanation

The Correct Answer is C

Correct answer: C) Moistening the new dressing with sterile water before wringing it out and applying it to the wound

Rationale: Wet-to-dry dressings are used for mechanical debridement of necrotic tissue from chronic wounds. The new dressing should be moistened with sterile water (not saline, as saline can cause sodium crystals to form on the wound bed and impair healing), wrung out to remove excess moisture (to prevent maceration of surrounding skin), and loosely packed into the wound (to allow contact with necrotic tissue). The old dressing should be removed dry (not soaked, as soaking can rehydrate necrotic tissue and reduce debridement).

Incorrect options:

A) Soaking the old dressing with sterile saline before removing it - This can rehydrate necrotic tissue and reduce debridement.

B) Applying antibiotic ointment to the new dressing before placing it on the wound - This can interfere with debridement and increase the risk of infection and resistance.

D) Covering the new dressing with an occlusive secondary dressing to prevent evaporation - This can create a moist environment that promotes bacterial growth and infection.

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Correct Answer is B

Explanation

Correct answer: B) Instruct the client to splint the incision when coughing

Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.

Incorrect options:

A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.

C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.

D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.

A. Partial-thickness wound B. Full-thickness wound C. Primary intention wound D. Secondary intention wound

Correct Answer is C

Explanation

Correct answer: C) Primary intention wound

Rationale: A primary intention wound is one that heals by epithelialization, with minimal tissue loss and scarring. The wound edges are approximated (closed), either naturally or by surgical means, and there is minimal drainage and inflammation. Granulation tissue is the new connective tissue that forms on the wound bed, indicating healing.

Incorrect options:

A) Partial-thickness wound - This is a wound that involves damage to the epidermis and part of the dermis, such as an abrasion or a blister. It heals by regeneration, with minimal scarring.

B) Full-thickness wound - This is a wound that involves damage to the epidermis, dermis, and underlying structures, such as a pressure ulcer or a surgical incision. It heals by granulation, contraction, and epithelialization, with significant scarring.

D) Secondary intention wound - This is a wound that heals by granulation, contraction, and epithelialization, with significant tissue loss and scarring. The wound edges are not approximated (open), either due to infection, trauma, or chronicity, and there is copious drainage and inflammation.

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A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?

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