A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. No drainage is noted. The nurse would treat the area with which dressing to promote healing?
Wet to dry dressing
No dressing is needed
Hydrocolloid dressing
Alginate
The Correct Answer is C
Rationale:
A. A wet-to-dry dressing is typically used for debridement and is not appropriate for a shallow pressure ulcer without necrotic tissue, as it can damage healthy tissue during dressing changes.
B. Leaving the area without a dressing is not advisable as it exposes the wound to contaminants and increases the risk of infection; a dressing should be used to protect the area.
C. A hydrocolloid dressing is ideal for shallow partial-thickness wounds as it provides a moist environment, promotes healing, and helps to cushion the area while maintaining a barrier against bacteria.
D. Alginate dressings are primarily used for wounds with moderate to heavy exudate and would not be suitable in this case due to the lack of drainage.
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Correct Answer is C
Explanation
Rationale:
A. Application of antibiotic ointment involves assessment and clinical judgment, which should be performed by a licensed nurse rather than an AP.
B. The removal of a nasogastric tube is a nursing task that requires training and knowledge of potential complications, and it should not be assigned to an AP.
C. Monitoring vital signs of a client who had an appendectomy 12 hours ago can be safely delegated to an AP, as it is a basic task that does not require clinical judgment beyond standard procedures.
D. Obtaining medical history information from a stable client is a task that requires assessment skills and critical thinking, making it inappropriate to assign to an AP.
Correct Answer is A
Explanation
Rationale:
A. Cleansing the wound with 0.9% sodium chloride saline irrigation helps remove debris and bacteria from the wound surface, ensuring that the specimen collected for culture reflects the infection present in the wound rather than contaminants.
B. Including intact skin at the wound edges in the culture is not advisable, as it may introduce flora that do not represent the infection. The focus should be on obtaining a specimen from the wound itself.
C. Swabbing an area of skin away from the wound to identify normal flora is not relevant when assessing an infection. The culture should target the actual infected area to determine the causative organisms.
D. Irrigating the wound with an antiseptic prior to obtaining the specimen can alter the bacterial load present and lead to inaccurate culture results, as it may kill or wash away organisms that need to be identified.