Asked by Jonathan Cidade on Jun 03, 2024

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The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action?

A) Wait and change the dressing at 1800 as ordered.
B) Revise the plan of care and change the dressing now.
C) Reassess the dressing and the wound in 2 hours.
D) Discontinue the plan of care for wound care.

Dressing Change

The process of removing old wound coverings and applying new ones, typically performed to promote healing and prevent infection.

Plan Of Care

A formally documented strategy developed by healthcare providers outlining the treatments and interventions for a patient's specific health needs.

Saturated

In chemistry, it refers to a solution that contains the maximum amount of solute that can be dissolved at a given temperature or to an organic molecule that has no double or triple bonds.

  • Safely execute and arrange nursing measures with priority.
  • Detect and modify treatment plans in response to patient advancement or absence of progress.
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Lakshmikanth reddy BandiathmakurJun 05, 2024
Final Answer :
B
Explanation :
Because the dressing is saturated and leaking, the nurse needs to revise the plan of care and change the dressing now. Reflection-in-action involves a nurse's ability to recognize how a patient is responding and then adjusting interventions as a result. A nurse will either change the frequency of an intervention, change how the intervention is delivered, or select a new intervention. Waiting until 1800 or for another 2 hours is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.