HESI RN Exit Proctored Exam
Select All That Apply
When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.
Explanation & Rationale
A: Consulting a wound care specialist ensures that proper infection management is initiated, and other treatment options, such as antimicrobial therapy, are considered. B: Discontinuing VAC therapy and cleansing the wound allows for infection control and proper evaluation of the wound's condition before resuming therapy. C: Reapplying the VAC system without addressing the potential infection could worsen the situation by promoting further bacterial growth. D: Documenting wound measurements is important but does not address the immediate infection, which should be the priority. E: Increasing the suction on the VAC system is inappropriate as it may exacerbate infection or tissue damage.
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