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NUR 204- Wound Care ATI

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NUR 204- Wound Care ATI

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NUR 204- Wound Care ATI
A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which
of the following types of dressings should the nurse select to help promote hemostasis?

a)Transparent

b)Hydrogel

c)Alginate

d)Dry gauze - (answer)c)Alginate



Feedback :

Alginate dressings help establish hemostasis while providing a moist environment for healing and
absorption of exudate. They do not adhere to the wound, so removal is unlikely to cause further
bleeding.




HINT:



a) Transparent film dressings are used for clients who have a stage 1 pressure injury with minimal
drainage.



b) Hydrogel dressings are used for clients who have a dry wound and minimal exudate.



d)Dry gauze can disrupt angiogenesis, the development of the vascular bed in the wound, thereby
causing further bleeding of the wound when removed.

A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in
the wound is watery in consistency and light red in color. The nurse should document which of the
following types of wound drainage?

a)Serosanguineous

, b)Sanguineous

c)Serous

d)Purulent - (answer)a)Serosanguineous



Feedback:

This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color.




HINT:



b) Sanguineous exudate is thin in consistency but bright red in color. This does not correlate with the
nurse's assessment findings.



c) Serous exudate is thin in consistency but clear in color. This does not correlate with the nurse's
assessment findings.




d) Purulent exudate can be thin or thick in consistency, but it is tan to yellow in color. This does not
correlate with the nurse's assessment findings.

A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing
considerable pain during dressing changes, despite administration of the prescribed analgesic prior to
wound care. Which of the following types of dressings should the nurse select to help minimize the pain
of dressing changes?

a)Wet-to-dry

b)Abdominal pads (ABD)

c)Dry gauze

d)Hydrogel - (answer)d)Hydrogel

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