RN Nursing · Pressure Injury, Wounds, and Wound Management · Practice question
The plan of care for a postoperative wound healing by primary intention specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information?
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Moisten sterile 4x4 gauze with 0.9% sodium chloride solution, pack wound and cover with dry sterile dressing.
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Contact the physician for a new order.
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Refuse to change the dressing and document the rationale for not changing the dressing.
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✓
Use a new sterile 0.9% sodium chloride-moisture swab or sterile gauze pad for each downward stroke.
Answer & explanation
Correct: Use a new sterile 0.9% sodium chloride-moisture swab or sterile gauze pad for each downward stroke.
When cleaning a wound healing by primary intention, the correct technique is to use a fresh sterile swab or sterile gauze pad for each downward stroke, moving from the cleanest area (incision line) outward to the surrounding skin. This prevents dragging bacteria from less clean areas back across the wound, thereby reducing infection risk. A new swab or gauze for each stroke is the standard aseptic wound-cleaning principle. Moistening gauze and packing the wound is incorrect for a primary-intention wound because these wounds are closed and do not require packing, which is a technique used for wounds healing by secondary or tertiary intention. Contacting the physician for a new order is unnecessary — using sterile saline to clean a postoperative wound is a safe, evidence-based practice, and the plan of care has already specified this approach. Refusing to change the dressing is also inappropriate, as wound care is within the nurse's scope and the plan of care is appropriate. The key principle here is aseptic technique: using a clean swab or gauze for each pass prevents cross-contamination and protects wound integrity during the healing process.
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