The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

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.

Choice A rationale:

The supine position with the head tilted toward the right eye allows the solution to flow away from the nose and mouth, preventing aspiration or discomfort.

Choice B rationale:

An upright position with the head tilted toward the left eye would cause the solution to flow into the nose and mouth, which could lead to aspiration or discomfort.

Choice C rationale:

An upright position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.

Choice D rationale:

A supine position with the head hyperextended would not allow for proper drainage of the solution, potentially causing discomfort or complications.