Podcast
Questions and Answers
What is the primary purpose of a sterile dressing?
What is the primary purpose of a sterile dressing?
- To absorb drainage (correct)
- To reduce pain
- To prevent allergic reactions
- To improve circulation
Which of the following is an appropriate cleansing solution for most sterile dressing changes?
Which of the following is an appropriate cleansing solution for most sterile dressing changes?
- Alcohol
- Hydrogen peroxide
- 0.9% Sodium Chloride (normal saline) (correct)
- Distilled water
Which of the following describes a wound healing by secondary intention?
Which of the following describes a wound healing by secondary intention?
- Surgical incision with approximated edges
- Burn with considerable tissue loss (correct)
- Fracture without skin breakage
- Sutured wound
A postoperative patient reports a sudden feeling of "pulling" in the abdominal wound. What complication does this indicate?
A postoperative patient reports a sudden feeling of "pulling" in the abdominal wound. What complication does this indicate?
What is the correct order of wound cleansing for a closed wound?
What is the correct order of wound cleansing for a closed wound?
Which dressing is primarily used for wound debridement?
Which dressing is primarily used for wound debridement?
What is the normal exudate that may be expected from a healing wound?
What is the normal exudate that may be expected from a healing wound?
Which assessment finding would indicate a possible wound infection?
Which assessment finding would indicate a possible wound infection?
What should a nurse do if a wound dressing adheres to the wound?
What should a nurse do if a wound dressing adheres to the wound?
What type of drainage is a pale, pink mixture of clear and red fluid?
What type of drainage is a pale, pink mixture of clear and red fluid?
When packing a wound, which of the following principles should be followed?
When packing a wound, which of the following principles should be followed?
Which of the following is a priority action if evisceration occurs?
Which of the following is a priority action if evisceration occurs?
What is a normal finding 48 hours after surgery?
What is a normal finding 48 hours after surgery?
Which of the following wounds heals by primary intention?
Which of the following wounds heals by primary intention?
How should a nurse measure the depth of a wound?
How should a nurse measure the depth of a wound?
When should sterile gloves be applied?
When should sterile gloves be applied?
What is considered a violation of sterile technique?
What is considered a violation of sterile technique?
Why must fluids be poured carefully onto a sterile field?
Why must fluids be poured carefully onto a sterile field?
What is the correct action when pouring a sterile solution?
What is the correct action when pouring a sterile solution?
Which part of a sterile field is considered unsterile?
Which part of a sterile field is considered unsterile?
In which setting is sterile technique always required?
In which setting is sterile technique always required?
Which of the following areas cannot be sterilized?
Which of the following areas cannot be sterilized?
What should a nurse do when the sterile field becomes contaminated?
What should a nurse do when the sterile field becomes contaminated?
What is the correct action when opening a sterile package?
What is the correct action when opening a sterile package?
What is the correct sequence when applying sterile gloves?
What is the correct sequence when applying sterile gloves?
What is the primary sign of evisceration in a postoperative wound?
What is the primary sign of evisceration in a postoperative wound?
Which of the following increases the risk of wound dehiscence?
Which of the following increases the risk of wound dehiscence?
What action is most appropriate if a wound dressing becomes saturated with drainage?
What action is most appropriate if a wound dressing becomes saturated with drainage?
Which of the following conditions is indicative of a wound infection?
Which of the following conditions is indicative of a wound infection?
Which of the following interventions promotes healing by secondary intention?
Which of the following interventions promotes healing by secondary intention?
Which is the correct technique for removing a soiled dressing?
Which is the correct technique for removing a soiled dressing?
Which of the following describes appropriate hand hygiene before donning sterile gloves?
Which of the following describes appropriate hand hygiene before donning sterile gloves?
What should a nurse do if they touch a non-sterile object while wearing sterile gloves?
What should a nurse do if they touch a non-sterile object while wearing sterile gloves?
In which direction should a nurse clean a wound to maintain sterility?
In which direction should a nurse clean a wound to maintain sterility?
Which of the following actions contaminates the sterile field during a dressing change?
Which of the following actions contaminates the sterile field during a dressing change?
Which part of a sterile glove is considered sterile?
Which part of a sterile glove is considered sterile?
What action is necessary when setting up a sterile field?
What action is necessary when setting up a sterile field?
What is the purpose of a wound vac in wound healing?
What is the purpose of a wound vac in wound healing?
How should a nurse dispose of soiled dressings after a dressing change?
How should a nurse dispose of soiled dressings after a dressing change?
What should be included in the documentation after performing a sterile dressing change?
What should be included in the documentation after performing a sterile dressing change?
When applying a new sterile dressing, what must the nurse document on the dressing?
When applying a new sterile dressing, what must the nurse document on the dressing?
What should a nurse do immediately after performing a sterile procedure?
What should a nurse do immediately after performing a sterile procedure?
Which sign would indicate delayed wound healing?
Which sign would indicate delayed wound healing?
What is the proper method for measuring the length of a wound?
What is the proper method for measuring the length of a wound?
A nurse is preparing to perform a sterile dressing change on a patient with an abdominal wound that is healing by secondary intention. Which action is most appropriate when cleaning the wound?
A nurse is preparing to perform a sterile dressing change on a patient with an abdominal wound that is healing by secondary intention. Which action is most appropriate when cleaning the wound?
A patient is two days post-surgery with a well-approximated incision. On assessment, the nurse observes mild erythema and slight edema at the incision site. What is the most appropriate nursing action?
A patient is two days post-surgery with a well-approximated incision. On assessment, the nurse observes mild erythema and slight edema at the incision site. What is the most appropriate nursing action?
When performing wound irrigation on a patient with a draining wound, which of the following techniques is essential to maintain a sterile field?
When performing wound irrigation on a patient with a draining wound, which of the following techniques is essential to maintain a sterile field?
During a sterile dressing change, the nurse notices that the patient’s wound has developed purulent drainage with a strong odor and increased warmth around the incision site. What is the nurse’s priority action?
During a sterile dressing change, the nurse notices that the patient’s wound has developed purulent drainage with a strong odor and increased warmth around the incision site. What is the nurse’s priority action?
A nurse is caring for a patient whose abdominal incision has dehisced. The patient reports feeling a “tearing” sensation. What should the nurse do immediately?
A nurse is caring for a patient whose abdominal incision has dehisced. The patient reports feeling a “tearing” sensation. What should the nurse do immediately?
Study Notes
Sterile Dressings and Wound Care
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Primary Purpose of Sterile Dressing: To protect a wound from contamination and promote healing.
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Appropriate Cleansing Solution: Normal saline is the most commonly used cleansing solution for sterile dressing changes.
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Wound Healing by Secondary Intention: This occurs when a wound is left open and the body heals from the bottom up. This happens when a wound is left open to drain or when there is a significant amount of tissue loss.
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Sudden "Pulling" Sensation in Abdominal Wound: This indicates wound dehiscence, a partial or complete separation of the wound edges.
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Wound Cleansing Order: The correct sequence is:
- Cleanse the wound from least contaminated to most contaminated, typically starting with the surrounding skin and then moving toward the center of the wound.
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Dressing for Debridement: Wet-to-dry dressings are primarily used for wound debridement.
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Normal Wound Exudate: Serous exudate, a clear, watery fluid, is expected in a healing wound.
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Indicators of Wound Infection: Signs include:
- Erythema (redness)
- Edema (swelling)
- Pain
- Warmth
- Purulent drainage (thick, yellow or green pus).
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Adherent Dressing: If a dressing adheres to the wound, gently moisten it with saline solution to loosen it. Do not pull or force the dressing off as this can damage delicate healing tissue.
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Serosanguineous Drainage: This is a pale, pink mixture of clear (serous) and red (sanguineous) fluid, commonly observed during wound healing.
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Wound Packing Principles:
- Pack loosely.
- Do not overpack the wound as this can impede circulation and healting.
- Ensure drainage can escape easily.
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Evisceration Priority Action: Immediately cover the wound with sterile saline-soaked gauze, notify the provider, and prepare the patient for surgery. This is a medical emergency requiring immediate intervention.
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Normal Finding After Surgery: Some mild swelling and slight redness around the incision site are considered normal 48 hours after surgery.
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Healing by Primary Intention: This occurs when a wound is closed directly with sutures, staples, or adhesive strips. Examples include surgical incisions.
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Measuring Wound Depth: Use a sterile cotton-tipped applicator and mark the length on the applicator with a sterile marker.
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Sterile Glove Application: Sterile gloves should be applied immediately before the procedure.
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Violation of Sterile Technique: Touching a non-sterile object is considered a violation of sterile technique.
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Pouring Fluids onto a Sterile Field: Pour fluids carefully to avoid splashing or contaminating the sterile area.
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Pouring Sterile Solution: Place the bottle cap face up on a flat surface and pour the solution from a distance to avoid contaminating the lip of the bottle.
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Unsterile Area of Sterile Field: The edges of the sterile field and anything below the table level are considered unsterile.
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Sterile Technique Setting: Sterile technique is always required in surgical settings.
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Non-Sterilizable Areas: Body cavities and the inside of the gastrointestinal system cannot be sterilized.
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Contaminated Sterile Field: If the sterile field becomes contaminated:
- Discard the contaminated items and start over with new sterile equipment.
- Do not attempt to reuse contaminated items.
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Opening Sterile Package:
- Open the package away from you.
- Avoid touching the inner surfaces of the package.
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Applying Sterile Gloves:
- Don the dominant hand glove first.
- Use the gloved hand to put on the other glove.
- Do not touch the outside of the gloves with bare hands.
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Evisceration Sign: Protrusion of internal organs through the wound is the primary sign of evisceration.
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Wound Dehiscence Risk Factors:
- Obesity
- Malnutrition
- Poor wound healing
- Excessive coughing or straining.
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Saturated Wound Dressing: Change the dressing immediately to prevent infection.
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Wound Infection Indicators:
- Increased redness, pain, swelling, warmth, and purulent drainage.
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Promoting Healing by Secondary Intention: Wound packing with moist dressings should be employed.
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Removing Soiled Dressing:
- Wear clean gloves.
- Remove the dressing in a single fluid motion.
- Avoid touching the wound.
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Hand Hygiene Before Donning Sterile Gloves:
- Wash hands thoroughly with soap and water for at least 20 seconds and dry them completely.
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Touching Non-Sterile Object: Discard the contaminated gloves and apply a new pair.
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Wound Cleaning Direction: Cleanse the wound from the least contaminated area to the most contaminated area.
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Contamination of Sterile Field: Touching the sterile field with an ungloved hand or a non-sterile instrument contaminates the sterile field.
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Sterile Glove Area: The inner surface of the sterile glove is considered sterile.
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Setting up a Sterile Field:
- The sterile field must be completely dry prior to placement of sterile equipment.
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Wound Vac Purpose: Negative pressure wound therapy (wound vac) promotes wound healing by removing wound exudate, reducing edema, and improving blood flow.
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Soiled Dressing Disposal:
- Dispose of soiled dressings in a biohazard waste container.
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Dressing Change Documentation:
- Record:
- The type and amount of drainage
- The wound appearance (size, color, odor)
- Any complications encountered.
- Record:
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New Dressing Documentation:
- Document the date and time of application of the new sterile dressing.
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Post-Sterile Procedure Action:
- Wash hands thoroughly with soap and water.
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Delayed Wound Healing Sign: Persistent inflammation or increased exudate can suggest delayed wound healing.
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Wound Length Measurement: Measure the length of the wound with a sterile ruler from end to end.
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Description
This quiz explores the primary purpose and functions of sterile dressings in medical practice. You'll learn about wound care principles and the importance of maintaining asterility to prevent infection. Test your knowledge on this critical aspect of healthcare.