The nurse is evaluating a return demonstration by the client of a dry dressing change. Which action by the client would cause the nurse to intervene? A)Client applies sterile adhesive dressing over gauze without touching the wound bed B)Client applies sterile gauze moistened with sterile saline to wound surface C)Client cleanses site with a sterile saline swab in a spiral pattern from the center out D)Client removes old dressing with clean gloves and checks site for signs of infection

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Quizplus · Accepted Answer

11ecbb05_cb80_8209_b433_df326713c69c_MD0009_00 Prior to discharge, the nurse must evaluate the client's ability to perform home wound care. When performing a simple dry dressing change, the client should: Don clean gloves and perform hand hygiene before and after removing the old dressing Cleanse the wound bed using sterile saline (or a prescribed cleanser) by moving from "clean" to "dirty," or from the center of the wound outward (Option C) Thoroughly dry the wound and surrounding skin using sterile gauze to prevent maceration (breakdown) of underlying tissues Monitor the site for signs of infection (eg, redness, warmth, purulent drainage) (Option D) Apply dry, sterile gauze over the wound bed Cover the gauze with an occlusive sterile dressing to keep gauze in place and maintain asepsis. The covering should be applied without touching the wound bed (Option A) (Option B) When performing a dry dressing change, the client must make sure that the bandaging materials applied (ie, gauze) are dry. Sterile gauze moistened with sterile saline is used for wet-to-dry dressing changes and is not appropriate for a dry dressing change. Educational objective: The nurse must evaluate a client's ability to perform home wound care before discharge. Instructions for a dry dressing change should include performing hand hygiene, properly cleansing the wound bed, drying the wound, monitoring for signs of infection, and securing a dry, sterile dressing to the wound surface.

The Nurse Is Evaluating a Return Demonstration by the Client