NCLEX · Basic Care and Comfort

What is the proper procedure for changing a sterile dressing on a surgical wound?

Correct answer

Hand hygiene; gather supplies; explain procedure; don clean gloves to remove old dressing; assess wound; perform hand hygiene; set up sterile field; don sterile gloves; clean wound from cleanest to dirtiest area using each gauze once; apply sterile dressing; document

  1. A No special technique required
  2. B Hand hygiene; gather supplies; explain procedure; don clean gloves to remove old dressing; assess wound; perform hand hygiene; set up sterile field; don sterile gloves; clean wound from cleanest to dirtiest area using each gauze once; apply sterile dressing; document
  3. C Change only when soiled
  4. D Use bare hands

Why this is the answer

Sterile dressing changes follow specific aseptic technique: (1) Hand hygiene, gather supplies, explain procedure to client, position appropriately; (2) Don clean gloves; remove old dressing carefully (note drainage, odor, intact ness); discard in appropriate container; remove gloves; perform hand hygiene; (3) Assess wound: size, location, color (red/yellow/black indicates healing/slough/necrotic), drainage, periwound skin, signs of infection (redness, warmth, pain, purulent drainage, odor); (4) Set up sterile field on clean, dry surface above waist level; (5) Don sterile gloves (or use sterile technique with no-touch method); (6) Clean wound from least contaminated to most contaminated (clean wound: center outward in concentric circles or strokes from top to bottom; contaminated wound: outside in); use each gauze once; clean with normal saline or prescribed solution; (7) Apply sterile dressing per orders (gauze, transparent film, hydrocolloid, etc.); (8) Secure with tape; document wound assessment, procedure, client tolerance. Maintain sterility — sterile to sterile, anything that touches non-sterile becomes non-sterile, sterile field at waist level minimum, keep within sight at all times.
Source: NCLEX-RN, Basic Care — Sterile Dressing Changes

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About this topic: Basic Care and Comfort

Basic care and comfort questions cover mobility, positioning, nutrition, elimination, hygiene, sleep and comfort measures, and the assistive devices and complementary therapies that support them. This is one of 6 RN: Physiological Integrity questions on basic care and comfort, each with a full explanation on a single study page.

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