Upon changing the client’s dressing, the nurse notes that the wound ap

Upon changing the client’s dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is:

1. Sterile saline
2. Hydrogen peroxide
3. Povidone-iodine (Betadine)
4. Sodium hypochlorite (Dakin’s solution)

ANSWER

ANS: 1
Pressure ulcers should be cleansed only with wound cleansers that are not cytotoxic, such as normal saline. Normal saline will not damage or kill cells, such as fibroblasts and healing tissue. Hydrogen peroxide, povidone-iodine (Betadine), and sodium hypochlorite (Dakin’s solution) are cytotoxic and therefore should not be used to clean a wound that is granulating.