What should the nurse do for a patient who is having a wet-to-dry dressing applied?
a. Moisten the old inner dressing to remove it.
b. Pack the gauze in flat pieces into the wound.
c. Wet the new inner dressing with a cytotoxic solution.
d. Apply a secondary dressing over the inner wet packing.
D
The primary purpose of wet-to-dry dressings is to mechanically debride a wound. The moistened contact layer of the dressing (primary dressing) increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound and debrides the wound of tissue when the dressing is removed. The moistened gauze must be covered with a secondary dressing layer that is dry. It is incorrect technique and a common error by some clinicians to moisten the dried gauze before removing it. This defeats the purpose of using this type of dressing and reduces the amount of debris that the dressing will remove. Open or "fluff" the woven gauze that will be placed directly against the wound bed. Moisten the packing material with a noncytotoxic solution such as normal saline. Never use cytotoxic solutions.
You might also like to view...
A community health nurse is making a family home visit. The family consists of the mother, father, a 1-year-old, and a 4-year-old
The mother tells you that the 4-year-old, who is in preschool, had a cold last week, and now the 1-year-old has it. She asks the nurse if she can use the over-the-counter cold medication that she gave to the 4-year-old for the 1-year-old. Which response would be most appropriate? A) "It shouldn't be a problem if you use that same medication for the 1-year-old." B) "I don't know if the medicine will work, but you can try it and see." C) "That type of medicine should not be used in children under age 2." D) "You should use a smaller dose, but watch if it makes him irritable."
The nurse is educating a 16-year-old girl who has just been diagnosed with acute myelogenous leukemia. Which of the following statements best demonstrates therapeutic communication?
A) Discussing the treatment plan in detail for the next few weeks B) Using medical terms when describing the disease C) Assessing the adolescent's emotional status in private D) Talking about clothing and the stores where she shops
Which problem or manifestation in a 125-pound, 40-year-old woman, 1-day postoperative for a total abdominal hysterectomy, leads the nurse to suspect possible substance abuse?
A. She has vomited nine times during the first 24 hours after surgery. B. Morphine 15 mg (subcutaneous) has failed to relieve her pain. C. She has been unable to void after removal of the Foley. D. Her wound drainage is greater than expected.
Which action by the nurse is most appropriate when conducting a spiritual assessment for a patient who is from a culture different from the nurse's culture?
1) Becoming familiar with the patient's cultural domain 2) Assuming the patient believes and practices everything within their cultural domain 3) Educating the patient on the nurse's cultural domain 4) Telling the patient that their beliefs are wrong and immoral