The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.
The nurse's most beneficial intervention would be to:

Moisten it with povidone iodine.

Pull it off using slow, steady pressure.

Add normal saline to loosen it.

Leave it in place and cover it with new, wet dressings.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Moistening the dressing with povidone iodine could cause irritation and is not the best method for removing a dressing stuck to the wound bed.

Choice B rationale:

Pulling off the dressing using slow, steady pressure could cause trauma to the wound bed and increase pain.

Choice C rationale:

Adding normal saline to loosen the dressing minimizes trauma to the wound bed and reduces pain during dressing removal.

Choice D rationale:

Leaving the old dressing in place and covering it with new, wet dressings could lead to infection and is not the best method for managing a dressing stuck to the wound bed.

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Correct Answer is D

Explanation

Choice A rationale:

Karaya paste is used for ostomy care, not for dressing changes.

Choice B rationale:

Paper tape might not provide the necessary adhesion for frequent dressing changes.

Choice C rationale:

Elastic adhesive tape is typically used for strains and sprains, not for dressing changes.

Choice D rationale:

Montgomery straps are adhesive strips that can be tied and untied to secure dressings without removing and reapplying tape. This can help reduce skin irritation from repeated tape removal.

A. Supine with the head tilted toward the right eye. B. Upright with the head tilted toward the left eye. C. Upright with the head hyperextended. D. Supine with the head hyperextended.

Correct Answer is A

Explanation

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

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The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.The nurse's most beneficial intervention would be to:

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Explanation

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Correct Answer is A

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The nurse changing a wet to dry normal saline dressing for a patient with an ulcer on the heel finds that the old dressing is stuck to the wound bed.
The nurse's most beneficial intervention would be to: