The nurse assesses the large raised scar on the African American patient.
The nurse documents the lesion as a:

Choice A rationale:

The goal of wound irrigation is to clean the wound, so the nurse should continue to irrigate until the drainage is clear.

Choice B rationale:

The irrigant should be at room temperature, not chilled.

Choice C rationale:

The syringe should be held 1 inch (not 0.5 inch) from the wound.

Choice D rationale:

The wound should be flushed from the cleanest area to the most contaminated, not the other way around.

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.