Author Question: The nurse is preparing to change a large wound dressing on the patient's buttock. Which intervention ... (Read 78 times)

mydiamond · **on:** Jul 22, 2018

The nurse is preparing to change a large wound dressing on the patient's buttock. Which intervention should the nurse address first?

a. Inspect the dressing for drainage.
b. Medicate appropriately before performing the dressing change.
c. Observe wound edges and if staples or sutures are intact.
d. Assess the insertion site of the drain(s).

Question 2

The nurse is caring for a patient with a necrotic hip wound. Which dressing would be the best choice for the nurse to use on this type of wound to help with debridement?

a. Dry gauze
b. Transparent film
c. Hydrogel
d. Hydrocolloid

cascooper22 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
When you plan a dressing change, consider giving the patient an analgesic at least 30 minutes before exposing a wound. Then assess the appearance of the wound. Next, assess the character of wound drainage by noting the amount, color, odor, and consistency. Then assess the drains. Drains lie within tissue, extend from the skin, and are connected to a drainage bag or suction apparatus or allowed to drain into a dressing. Most drains attach to a collection device. First, observe the security of the drain and its location with respect to the wound. Next, note the character and amount of drainage if there is a collecting device. In the case of a surgical wound, inspect the staples, sutures, or wound closures for irritation, and note whether the wound edges are intact.

Answer to Question 2

C
Hydrogel dressings are available in sheets or in a gel in a tube (amorphous). They contain a high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue). Gauze dressings are best for wounds with moderate drainage, deep wounds, undermining, and tunnels. Transparent film dressings are used as a primary dressing in wounds with minimal tissue loss that have very little wound drainage. Hydrocolloid dressings are used for stage I, II, and III pressure ulcers.