Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 10==
A registered nurse assesses a bedbound client and finds a dry, black, firmly adherent, intact eschar over the left heel with no surrounding erythema, fluctuance, drainage, or odor. Which action is most appropriate?
# Request an order for sharp debridement of the eschar.
# Apply a hydrogel dressing to soften and remove the eschar.
# Keep the eschar dry and intact, offload the heel, and monitor for changes.
# Apply wet-to-dry gauze dressings three times daily.

'''Answer:''' 3 (C). Keep the eschar dry and intact, offload the heel, and monitor for changes.

''Rationale:'' Stable, dry, adherent eschar on an ischemic heel serves as the body's natural biological cover and should not be removed. It is documented as an unstageable pressure injury. The nursing priority is pressure redistribution with heel offloading, keeping the eschar dry, and reporting any new erythema, fluctuance, drainage, odor, or softening, which would indicate infection and change the plan. Options 1, 2, and 4 all remove or moisten the protective eschar and would expose poorly perfused tissue to infection.