The nurse is performing a moist-to-dry dressing. The nurse has ...

[joblessjake]

The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one?
 
  1. Apply sterile gloves.
  2. Cover and secure topper dressing.
  3. Assess wound and surrounding skin.
  4. Moisten gauze with prescribed solution.
  5. Gently wring out excess solution and unfold.
  6. Loosely pack until all wound surfaces are in contact with gauze.
  a. 4, 3, 1, 5, 6, 2
  b. 1, 3, 4, 5, 6, 2
  c. 4, 1, 3, 5, 6, 2
  d. 1, 4, 3, 5, 6, 2

Question 2

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan?
 
  a. Readiness for enhanced nutrition
  b. Impaired physical mobility
  c. Impaired skin integrity
  d. Chronic pain

[spencer.martell]

Answer to Question 1

ANS: B
The steps for a moist-to-dry dressing are as follows: (1) Apply sterile gloves; (2) assess appearance of surrounding skin; (3) moisten gauze with prescribed solution. (4) Gently wring out excess solution and unfold; apply gauze as single layer directly onto wound surface. (5) If wound is deep, gently pack dressing into wound base by hand until all wound surfaces are in contact with gauze; (6) cover with sterile dry gauze and secure topper dressing.

Answer to Question 2

ANS: C
After the assessment is completed and the information that the patient has a Stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain do not support the current data in the question.

[joblessjake]

Excellent

[cam1229]

TYSM