Author Question: The nurse is changing the client's dressing on a postoperative nondraining wound. Which personal ... (Read 136 times)

jenna1 · **on:** Jun 25, 2018

The nurse is changing the client's dressing on a postoperative nondraining wound. Which personal protective equipment (PPE) would the nurse don prior to the dressing change?

1. Sterile gown, mask, and sterile gloves
2. Sterile gown, mask, and goggles
3. Sterile gloves and mask
4. Sterile gloves

Question 2

The nurse is admitting a client with a pressure ulcer to the long-term care facility. When assessing the wound, the nurse finds partial-thickness skin loss free of eschar. Which stage will the nurse document this ulcer as based on the assessment data?

1. Stage I
2. Stage II
3. Stage III
4. Stage IV

jharrington11 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 3

Applying a face mask will reduce the risk of contamination of the wound by droplet spray from the nurse's respiratory tract. Sterile gloves are worn to prevent contamination of the dressing. Goggles and gowns are needed only if the wound is contaminated and there is a risk of spray.

Answer to Question 2

Correct Answer: 2

A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure relief. A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.