A nurse is collecting data on a client who has impaired mobility.
The nurse should monitor the client for a pressure injury due to which of the following factors?

Choice A rationale:

Superficial wounds heal faster when kept moist.

Choice B rationale:

Wet-to-dry dressings are not typically used for superficial wounds as they can cause trauma to the wound bed during removal.

Choice C rationale:

Occlusion can help maintain a moist environment, but it’s not the only factor in wound healing.

Choice D rationale:

Debridement is the removal of dead or infected tissue from a wound, which can promote healing, but it’s not the only factor.

Choice A rationale:

Increased pallor of the surgical site is not a typical sign of wound dehiscence. It could indicate poor blood flow to the area, but it’s not directly related to dehiscence.

Choice B rationale:

Increased serosanguineous drainage from the wound is a common sign of wound dehiscence. This type of drainage is a mixture of blood and serum, and an increase could indicate that the wound edges are separating.

Choice C rationale:

Excessive gas is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as ileus or bowel obstruction, but not specifically to dehiscence.

Choice D rationale:

Complaint of constipation is not a typical sign of wound dehiscence. It could be related to other postoperative complications, such as side effects of pain medication or decreased mobility, but not specifically to dehiscence.