HESI Registered Nurse EXIT Practice Exam

A home health nurse sees a client with a pressure sore categorized by redness and serous drainage. What dressing is most appropriate?

1. Wet dressing with debridement granules

2. Moist saline dressing

3. A transparent film dressing

4. Wet to dry with hydrogen peroxide

The correct answer is: Moist saline dressing

The most appropriate dressing for a pressure sore characterized by redness and serous drainage is a moist saline dressing. This type of dressing is beneficial because it helps maintain a moist wound environment, which can promote healing and minimize pain. Additionally, using a saline dressing can help cleanse the wound by drawing excess exudate away while not being too aggressive, thereby preventing further injury to the already compromised tissue. A moist saline dressing is generally non-adherent, which makes it easier to remove without causing trauma to the surrounding skin or to the wound itself. In cases where there is redness, this suggests potential inflammation, and a saline dressing can soothe the area while providing necessary moisture. Other dressing options may not be as suitable in this case. For instance, wet dressings with debridement granules could be too abrasive and therefore may not be ideal for a wound characterized by redness, as they might cause further irritation. A transparent film dressing, while it provides a barrier and allows for easy monitoring, may not absorb the serous drainage adequately. Lastly, wet-to-dry dressings with hydrogen peroxide could lead to further tissue damage since they can be too drying and cause additional trauma upon removal.