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 A
Explanation
Choice A rationale
The second stage of wound healing is proliferation, which occurs after the initial hemostasis phase. During proliferation, the wound begins to be rebuilt with new, healthy granulation tissue. This tissue is rich in collagen, which forms a foundation for new tissue growth. Capillaries grow across the wound, bringing oxygen and nutrients that are essential for healing. New skin cells begin to form over this granulation tissue, which is a critical component of the healing process.
Choice B rationale
Maturation is the third and final stage of wound healing. It follows the proliferation stage and involves the remodeling of collagen, which strengthens the tissue and restores its normal function. During maturation, the new tissue slowly gains strength and flexibility. Here, the collagen fibers reorganize, the tissue remodels and contracts, and the healed wound becomes more resilient. This stage can take a long time, sometimes up to a year or more, depending on the wound’s severity and the patient’s overall health.
Choice C rationale
Inflammation is indeed the second stage of wound healing. It is a natural part of the healing process and involves controlling bleeding, preventing infection, and enabling the migration of healing cells to the wound area.
Choice D rationale
Remodeling is the last stage of wound healing, not the second. It occurs after the wound has closed and involves the long-term strengthening and formation of scar tissue.
Correct Answer is C
Explanation
Choice A rationale
Excessive gas is not typically an indication of wound dehiscence. While it may cause discomfort, it does not suggest that the wound layers have separated.
Choice B rationale
A complaint of constipation is a common postoperative concern due to decreased mobility and use of narcotics but is not a sign of wound dehiscence.
Choice C rationale
Increased drainage from the wound, especially if the fluid is clear or serous, can be an early sign of dehiscence, indicating that the wound layers are separating and fluid is accumulating.
Choice D rationale
Increased pallor of the surgical site might indicate poor perfusion but is not a direct sign of dehiscence. Dehiscence would more likely show signs of inflammation or unusual discharge.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.