While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?
Leave it in place and cover it with new, wet dressings.
Moisten it with povidone-iodine.
Add normal saline to loosen it.
Pull it off using slow, steady pressure.
The Correct Answer is C
Choice A rationale
Leaving the old dressing in place and simply covering it with new wet dressings would not address the issue of the dressing being adhered to the wound bed, which could lead to further tissue damage when it is eventually removed.
Choice B rationale
Povidone-iodine is an antiseptic and not typically used to moisten dressings that are stuck to a wound bed, as it may irritate the wound and delay healing.
Choice C rationale
Adding normal saline is the gentlest method to loosen a dressing that is stuck to a wound bed. It helps to rehydrate the dressing and the wound, making it easier to remove without causing additional trauma to the healing tissue.
Choice D rationale
Pulling off the dressing using slow, steady pressure could cause damage to the new tissue forming in the wound bed and should be avoided unless all other methods have failed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A rationale
Anticholinergics are not typically associated with delayed wound healing. These medications affect the parasympathetic nervous system and are used to treat a variety of conditions, but they do not have a direct impact on the wound healing process.
Choice B rationale
Corticosteroids can delay wound healing. They are known to have anti-inflammatory properties, which can suppress the immune response necessary for wound healing. They also reduce the production of collagen and other proteins essential for tissue repair.
Choice C rationale
Beta-blockers are primarily used to manage cardiovascular conditions and are not known to have a significant impact on wound healing. They work by blocking the effects of adrenaline on the heart and blood vessels.
Choice D rationale
Tricyclic antidepressants are used to treat depression and certain types of pain. While they can have various side effects, they are not commonly associated with delayed wound healing.
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