Difficulty: Medium
Average Score: 85%
Simulated
When observing a dressing change by a graduate nurse on a Stage III pressure ulcer to the greater trochanter by the staff nurse, a need for further teaching is indicated after the following observation by the nurse:
Correct answer
B
Rationale
The correct answer is that the new graduate irrigates the pressure ulcer with half-strength hydrogen peroxide. Pressure ulcers should not be cleaned with substances that are cytotoxic, such as hydrogen peroxide or betadine. This can cause further damage to the wound and delay the healing process. Choice A is incorrect because irrigating the pressure ulcer with normal saline is an appropriate practice. Choice C is incorrect because packing the wound with sterile kerlix soaked in normal saline is also an appropriate step. Choice D is incorrect because applying a Duoderm dressing after cleansing is a standard procedure in wound care.