The nurse is caring for an 84-year-old patient who was just admitted with a large sacral ulcer. When assessing the wound, the nurse notes small areas of both black and white tissue in the wound bed
Which dressing protocol would the nurse expect to follow with this wound? 1. Wet-to-dry with normal saline every 6 hours
2. Dry dressing twice per day
3. Wet-to-wet with Dankins solution once per day
4. Petroleum-based antiseptic dressing once per day
1
Rationale 1: The black and white tissue must be debrided from the wound area before healing can occur. Wet-to-dry dressing provides a means of debridement.
Rationale 2: The black and white tissue must be debrided from the wound area before healing can occur. Dry dressings cover the wound but do not provide the needed debridement.
Rationale 3: The black and white tissue must be debrided from the wound area before healing can occur. Wet-to-wet dressings do not adhere to the wound; therefore, no debridement is provided.
Rationale 4: The black and white tissue must be debrided from the wound area before healing can occur. Petroleum-based products would not provide debridement.
You might also like to view...
The nurse assists with admission of a patient to the hospital with pancreatitis and a history of alcohol abuse. Why is it important for the nurse to observe the patient for agitation, tremors, and hallucinations?
a. These symptoms indicate possible cirrhosis of the liver. b. These are symptoms of alcohol withdrawal. c. Patients with a history of alcohol abuse are at risk for mental illness. d. The patient may be using alcohol in the hospital setting.
The home care nurse hears the spouse of an older client say "You have been so sick but you insist on living in this huge home that you cannot maintain but expect me to."
The client engages in an argument with the spouse. Which does the home care nurse identify as occurring with this couple? A) Evidence of low blood glucose levels B) Financial struggles within the family C) Possible situational depression for both client and spouse D) Spousal abuse
A nurse is assisting with the delivery of twins
The first infant is placed on the scale to be weighed. The physician requests an instrument stat. The nurse turns to hand the instrument to the physician, and the infant falls off the scale. When evaluating the incident, the nurse and her manager list contributory factors such as the need for two nurses when multiple births are known, and the location of the scale so far from the delivery field. These nurses are performing a(n): a. standardization of care. b. root cause analysis. c. process variation. d. analysis of a deployment flowchart.
The nurse is providing teaching to a patient who will begin taking aspirin to treat arthritis pain. Which statement by the patient indicates a need for further teaching?
a. "I should increase fiber and fluids while taking aspirin." b. "I will call my provider if I have abdominal pain." c. "I will drink a full glass of water with each dose." d. "I will notify my provider of ringing in my ears."