What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?

Tegaderm or Opsite

Abdominal pads held in place with paper tape

Retention

Montgomery straps

Answer and Explanation

The Correct Answer is D

Choice A rationale
Tegaderm or Opsite dressings are transparent and adhesive, allowing for wound inspection without removal, but they do not involve tape that remains in place for multiple changes.

Choice B rationale
Abdominal pads held in place with paper tape would require the tape to be removed and replaced with each dressing change, which can disrupt the skin.

Choice C rationale
The term ‘retention’ is incomplete and does not specify a type of dressing. Retention typically refers to the ability to keep something in place, such as a dressing, but does not imply that the tape remains in place.

Choice D rationale
Montgomery straps are designed with ties that attach to an adhesive base that remains on the skin. This allows the dressing to be changed without removing and reapplying tape, thus preventing skin disruption.

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Correct Answer is C

Explanation

Choice A rationale
Sanguineous drainage is indicative of active bleeding and is typically bright red due to the presence of red blood cells. This type of drainage is not yellow-red and is not consistent with the description provided.

Choice B rationale
Serous drainage is clear and watery, and it is the fluid that is seen in blisters. It does not have a yellow-red color, so it does not match the description of the drainage observed.

Choice C rationale
Serosanguineous drainage is a mixture of serous and sanguineous drainage. It is typically light red or pink in color, which corresponds with the moist yellow-red stain described, indicating the presence of both plasma and red blood cells.
Choice D rationale
Purulent drainage is thick and opaque, usually yellow, green, or brown, and is associated with infection. The description of a yellow-red stain does not suggest that the drainage is purulent.

A. Applying hydrocolloids to the wound bed. B. Pulsating lavage. C. Using a topical enzyme solution in the wound bed. D. Placing a transparent dressing over the pressure injury.

Correct Answer is B

Explanation

Choice A rationale
Applying hydrocolloids to the wound bed is not a form of mechanical debridement. Hydrocolloids are dressings that provide a moist environment and promote autolytic debridement but do not mechanically remove necrotic tissue.

Choice B rationale
Pulsating lavage is a form of mechanical debridement. It involves the use of a pressurized, pulsed solution to cleanse and remove debris and necrotic tissue from the wound bed, which is essential for the healing process of a stage 4 pressure injury.

Choice C rationale
Using a topical enzyme solution in the wound bed is a chemical, not mechanical, method of debridement. Enzymatic debridement uses proteolytic enzymes to break down necrotic tissue without affecting viable tissue.

Choice D rationale
Placing a transparent dressing over the pressure injury is not a form of debridement. Transparent dressings allow for oxygen exchange and protect the wound from infection, but they do not debride the wound.

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What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When changing the dressing on the patient’s right arm, you see that the dressing has a moist yellow-red stain on it. How would you document this drainage?

Correct Answer is C

Explanation

A nurse is caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Correct Answer is B

Explanation

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