A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.

Which of the following techniques should the nurse use when performing this dressing change?

Remove the tape by pulling from the center of the dressing

Wear sterile gloves to remove the dressing

Clean the wound from the center to the outer edges

Moisten the dressing before removal

Answer and Explanation

The Correct Answer is C

When removing the dressing and cleaning the wound, it is important to start from the center of the wound and work towards the outer edges. This technique helps prevent contamination of the wound by minimizing the risk of dragging bacteria or debris from the surrounding skin into the wound.

The other options listed are not recommended for this specific procedure:

When removing the tape, it is generally recommended to pull it parallel to the skin surface rather than pulling from the center of the dressing. This technique reduces the risk of causing trauma or disrupting the wound.

While it is important to maintain aseptic technique during dressing changes, wearing sterile gloves is not necessary for a wet-to-dry dressing change. Clean, non-sterile gloves are typically sufficient for this procedure, as the dressing material itself is not sterile.

In a wet-to-dry dressing change, the dressing is typically applied moist and allowed to dry over time. Therefore, moistening the dressing before removal is not necessary. The primary goal is to remove the dry dressing, which may adhere to the wound bed, and then clean the wound before applying a fresh dressing.

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Correct Answer is D

Explanation

Diminished pulses in the affected extremity can indicate compromised circulation, which is a serious concern. It could suggest the development of compartment syndrome, a condition characterized by increased pressure within the muscles and tissues of the leg. Compartment syndrome can lead to tissue damage and potentially jeopardize the client's limb. Therefore, it is crucial for the nurse to recognize and address this finding promptly.

One fingerbreadth of space between the cast and the skin is generally considered an appropriate amount of space to allow for swelling and adequate circulation. However, it should still be monitored for any changes or signs of compartment syndrome.

Ecchymosis on the inner left thigh may indicate bruising, which could be related to the injury or the application of the cast. While it should be documented and monitored, it does not pose an immediate threat to the client's well-being.

Client report of muscle spasms of the left leg can be a common occurrence due to muscle immobility and discomfort associated with the cast. Although it should be assessed and managed for the client's comfort, it is not as urgent as addressing compromised circulation

A. "I can have two glasses of wine with dinner." B. "I will set my blood pressure goal at 130 over 84. C. "I should decrease my salt intake to 2 grams per day." D. "I should exercise for 15 minutes two times per week."

Correct Answer is C

Explanation

"I should decrease my salt intake to 2 grams per day." - This statement is correct. Decreasing salt intake is an important dietary modification for individuals with hypertension. The general recommendation is to limit sodium intake to 2 grams per day or less. Reducing salt intake can help lower blood pressure levels.

"I can have two glasses of wine with dinner." - This statement is not accurate. While moderate alcohol consumption may have some health benefits, it is generally recommended to limit alcohol intake, especially for individuals with hypertension. The specific recommendation for alcohol consumption may vary depending on individual factors and should be discussed with a healthcare provider.

"I should exercise for 15 minutes two times per week." - This statement is not accurate. While any amount of physical activity is beneficial, the current recommendations for adults include at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities on two or more days. The client should aim for a higher frequency and duration of exercise to achieve optimal health benefits.

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A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound. Which of the following techniques should the nurse use when performing this dressing change?

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A nurse is preparing to perform a wet-to-dry dressing change for a client who has an infected abdominal wound.

Which of the following techniques should the nurse use when performing this dressing change?