The nurse changes the client's IV dressing and removes the existing transparent wound barrier. Prior to applying the new barrier, which action by the nurse is the most appropriate?
1. Applying benzoin to make the dressing stick firmly
2. Placing a sterile piece of gauze over the insertion site before placing a new transparent barrier over the wound
3. Cleansing the site with normal saline or a mild cleansing agent
4. Applying sterile gloves
3
Rationale 1: Benzoin is not needed, but the dressing can be window-paned with tape if needed.
Rationale 2: Placing a piece of gauze over the insertion site defeats the purpose of the transparent dressing and makes it impossible to see the site to monitor for changes, so it is contraindicated.
Rationale 3: The nurse should clean the site with normal saline or a mild cleansing agent to reduce pathogen exposure into the wound.
Rationale 4: It is not necessary to wear sterile gloves, because the nurse should not touch the insertion site directly, and does not touch the sterile dressing. Clean gloves should be worn to protect the nurse.
Global Rationale: The nurse should clean the site with normal saline or a mild cleansing agent to reduce pathogen exposure into the wound. It is not necessary to wear sterile gloves, because the nurse should not touch the insertion site directly, and does not touch the sterile dressing. Clean gloves should be worn to protect the nurse. Benzoin is not needed, but the dressing can be window-paned with tape if needed. Placing a piece of gauze over the insertion site defeats the purpose of the transparent dressing and makes it impossible to see the site to monitor for changes, so it is contraindicated.
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