Question

A nurse is caring for a patient whose wound is draining heavy serosanguineous exudate. Which nursing intervention would be most effective for preventing infection for this patient?

a) Monitoring the wound for redness, swelling, and purulent drainage

b) Changing the dressing as ordered when it becomes soiled

c) Notifying the health care provider if the patient develops a fever or an increased WBC count

d) Wearing gloves, gown, mask, and eyewear during dressing changes

Answer 1

Ans) d)Wearing gloves, gown, mask, and eyewear during dressing changes

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Explaination:

Principles of wound cleansing:

Use Aseptic Technique procedure- a non-touch technique is used to protect key parts and key sites. If a key part or key site is to be touched directly then sterile gloves must be worn. Note: when using a disinfectant on a key site (e.g. skin) or key part (e.g. injection port) it must be allowed to dry.
Cleansing should be performed in a way that minimises trauma to the wound as new epithelial cells and vessels are fragile.
Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure and loosen debris. Gauze swabs and cotton wool should be used with caution.
Wounds are best cleansed with sterile isotonic saline or water, warmed to body temperature.