Questions: The nurse is observing the patient's wife perform treatment of her husband's pressure injury. Which action, if made by the patient's wife, indicates that further instruction is needed? She premedicates the patient for pain before beginning the dressing change. She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water. While wearing gloves, she rinses the injury with normal saline, gently wiping around the wound base and surrounding skin with moistened gauze. She applies solution to the gauze and wrings out any excess. She unfolds the gauze and packs the wound with the moistened dressing. She covers the gently packed wound with dry 4 × 4-inch gauze pads and applies tape to secure the dressing. She removes her gloves and performs hand hygiene.

The answer is: She performs hand hygiene and removes the old dressing and begins to clean the injury with soap and water.

This action is appropriate as it helps manage the patient's pain during the dressing change, which can be a painful procedure. Premedicating for pain is a standard practice in wound care to ensure patient comfort.

This action indicates that further instruction is needed. Cleaning a pressure injury with soap and water is not recommended as it can be too harsh and may damage the tissue. Instead, normal saline or a wound cleanser should be used to clean the wound gently.

This is an appropriate action. Using normal saline to rinse the wound is a standard practice as it is gentle and does not irritate the tissue. It helps in cleaning the wound without causing additional harm.

This action is correct. Packing the wound with moistened gauze helps maintain a moist wound environment, which is conducive to healing. Covering it with dry gauze and securing it properly is also appropriate. Performing hand hygiene after removing gloves is a necessary step to prevent infection.