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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
Prolonged immobility can indeed cause swelling due to fluid accumulation; however, it typically does not lead to sudden worsening or significant swelling at a specific wound site. It is more associated with generalized edema, particularly in dependent areas of the body.

Choice B rationale
While infections can cause swelling, they are also accompanied by other signs such as redness, warmth, pain, and possibly fever. Swelling alone, without these other symptoms, is less indicative of an infection.

Choice C rationale
A deeper injury might cause swelling, but this would have been identified during the initial assessment. Swelling that occurs later in the healing process is less likely to be from a deeper, previously unnoticed injury.

Choice D rationale
Swelling at a wound site is often due to inflammation, where blood vessels dilate and become more permeable, allowing plasma to leak into the tissue. This is a normal part of the healing process as the body brings in necessary cells and substances to promote recovery.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:

Correct Answer is D

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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