Author Question: Which of the following is an accurate step when applying a saline-moistened dressing on a client's ... (Read 31 times)

jjjetplane · **on:** Jul 23, 2018

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound?

A) Do not use irrigation to clean the wound before changing the dressing.
B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it.
C) Exert light pressure to pack the wound tightly with moistened dressing.
D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.

Question 2

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?

A) Stage I
B) Stage II
C) Stage III
D) Stage IV

Loise Hard · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: D
Answer D is the correct step in the procedure. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom, and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The dressing should be gently and loosely packed inside the wound.

Answer to Question 2

Ans: C
In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence. In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.