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    Ati Rn Paediatrics Nursing 2023 Proctored Exam

    A nurse is performing a dressing change for a child and notices that the gauze dressing is adhering to the wound bed. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Apply firm pressure to the wound base while removing the gauze dressing: Applying firm pressure can disrupt newly formed granulation tissue and increase pain and bleeding. This approach may delay wound healing and cause unnecessary trauma, especially in pediatric clients. B. Saturate the gauze dressing with sterile saline solution prior to removing it: Moistening the dressing with sterile saline helps loosen adhered gauze from the wound bed. This reduces tissue trauma, minimizes pain, and preserves healthy granulation tissue during dressing removal. C. Continue to remove the gauze dressing by pulling it parallel to the skin: Pulling the dressing, even parallel to the skin, can still tear fragile tissue if the gauze is stuck. This method does not address the issue of the gauze being stuck to the internal wound bed.and may worsen wound injury. D. Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing: Hydrogen peroxide is cytotoxic to healthy tissue and can impair wound healing. Its use is generally avoided for routine wound care and is not appropriate for loosening an adhered dressing.

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