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 D
Explanation
Choice A rationale
Pointing the device away while opening it is a safe practice to prevent contamination and accidental exposure to bodily fluids.
Choice B rationale
Not touching the drainage spout with the hand is correct as it prevents contamination of the spout, which could lead to infection.
Choice C rationale
Compressing the device before closing it is part of the proper procedure to re-establish the vacuum within the drain, which is necessary for it to function correctly.
Choice D rationale
Using one alcohol wipe to clean both the spout and the plug is incorrect because each should be cleaned with a separate sterile wipe to prevent cross-contamination and maintain sterility.
Correct Answer is D
Explanation
Choice A rationale
Preparing a discard bag next to the wound is a practical step in the process, but it is not the most critical action to prevent infection.
Choice B rationale
Remaining very still during the procedure is important, but it does not directly relate to maintaining the sterility of the dressing change.
Choice C rationale
Restraining from moving the patient is not typically necessary unless the patient is at risk of causing harm to themselves or disrupting the procedure.
Choice D rationale
Changing gloves after removing the old dressing is crucial to maintain sterility. The old dressing may be contaminated, and fresh gloves reduce the risk of introducing bacteria to the clean wound.
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