A nurse cares for a client who has a deep wound that is being ...

[Shelles]

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this client's plan of care?
 
  a. Change the dressing every 6 hours.
  b. Assess the wound bed once a day.
  c. Change the dressing when it is saturated.
  d. Contact the provider when the dressing leaks.

Question 2

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next?
 
  a. Turn the mattress overlay to the opposite side.
  b. Do nothing because this is an expected occurrence.
  c. Apply a different pressure-relieving device.
  d. Reinforce the overlay with extra cushions.

[dellikani2015]

Answer to Question 1

ANS: A
Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum dbridement. The wound should be assessed each time the dressing is changed. Dry gauze dressings should be changed when the outer layer becomes saturated. Synthetic dressings can be left in place for extended periods of time but need to be changed if the seal breaks and the exudate leaks.

Answer to Question 2

ANS: C
Bottoming out, as evidenced by deep imprints in the mattress overlay, indicates that this device is not appropriate for this client, and a different device or strategy should be implemented to prevent pressure ulcer formation.

[Shelles]

Gracias!

[juliaf]

TYSM