Question

The nurse observes edema and abrasions at the wound area under an elastic bandage. Which nursing action is the priority?

1 Loosening the bandage
2 Changing the bandage
3 Removing the bandage
4 Reporting to the health care provider

Answer 1

The nurse's priority action when observing edema and abrasions under an elastic bandage is to remove the bandage to prevent further harm, assess the wound for infection, and report to the health care provider.

Step-by-step explanation:

If a nurse observes edema and abrasions at the wound area under an elastic bandage, the priority nursing action is to remove the bandage. This immediate response is necessary to prevent further harm and to evaluate the condition of the wound. Continued constriction from an overly tight bandage can lead to complications such as compromised blood flow and increased risk of infection. Once the bandage is removed, it is crucial to assess the wound for signs of infection, such as increased redness, swelling, warmth, and pain. If any signs of infection are present, it is necessary to clean the wound and apply a new bandage, possibly with a topical antibiotic if prescribed. Additionally, the nurse should report these findings to the health care provider for further instruction and potential adjustment of the treatment plan.