The nurse removes the dressing from a patient’s stage IV pressure injury and notes a foul odor and yellow drainage on the dressing and from the wound bed. Which of the following is the most appropriate next course of action?

Cleanse the wound. Prior to properly assessing the wound, the nurse must discard the old dressing and cleanse the wound. Once the wound is cleansed, the nurse can adequately visualize and measure the wound and assess the odor. If the foul smell or other indications of infection remain after the wound is cleaned, topical or systemic antibiotics may be indicated.

The nurse removes the dressing from a patient’s stage IV pr...

Category: Physiological Adaptation
Difficulty: 5

Topics: Communication & Documentation

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