What stage is a wound if the epidermis is closed and has unblanchable redness?

Stage 1

Stage 2

Stage 3

stage 4

Answer and Explanation

The Correct Answer is A

Choice A rationale

A wound at Stage 1 is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The skin remains unbroken with persistent redness that does not turn white when pressed. This stage indicates that the epidermis is closed.

Choice B rationale

Stage 2 involves partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. This stage is not applicable if the epidermis is closed.

Choice C rationale

Stage 3 is defined by full-thickness skin loss, where fatty tissue is visible in the wound, and granulation tissue and epibole (rolled wound edges) are often present. This stage indicates a more severe wound than what is described in the scenario.

Choice D rationale

Stage 4 represents full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. The condition described does not match the severity of a Stage 4 wound.

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Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula is not typically indicated in the initial stage of wound healing. Oxygen therapy is used for clients with respiratory distress or hypoxia, not as a standard wound care procedure.

Choice B rationale
Mechanical debridement is a method used to remove dead tissue from wounds, but it is not usually part of the initial wound care plan. Debridement is considered when there is necrotic tissue present that may impede healing.

Choice C rationale
Leaving non-bleeding wounds open to air can be beneficial during the initial stage of wound healing. Exposure to air can help to dry out the wound and prevent maceration of the surrounding skin. It also allows for the observation of the wound and easy access for dressing changes if needed.

Choice D rationale
Administering a corticosteroid medication is not a standard part of initial wound care. Corticosteroids can actually delay wound healing and are generally avoided unless there is a specific indication, such as an inflammatory skin condition.

A. Abdominal pads B. Hydrogel C. Wet-to-dry D. Dry gauze

Correct Answer is B

Explanation

Choice A rationale
Abdominal pads are generally used for absorption and are not specifically designed to minimize pain during dressing changes.

Choice B rationale
Hydrogel dressings provide moisture to the wound, which can facilitate autolytic debridement and reduce pain during dressing changes. They are cooling and soothing, which can be comfortable for the patient.

Choice C rationale
Wet-to-dry dressings are used for mechanical debridement and can be painful when removed, as they may adhere to the wound bed and pull on new tissue.

Choice D rationale
Dry gauze can adhere to the wound and cause pain upon removal, similar to wet-to-dry dressings, and is not the best choice for minimizing pain.

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What stage is a wound if the epidermis is closed and has unblanchable redness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

While changing a wet-to-dry normal saline dressing for a patient with an ulcer on the heel, the nurse finds that the old dressing is stuck to the wound bed. What would be the most beneficial intervention by the nurse?

A nurse is caring for a client who has a stage 4 sacral pressure injury. The provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

What stage is a wound if the epidermis is closed and has unblanchable redness?

When preparing to change a sterile dressing over an incision, it is most important to remember to:

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

The nurse is performing a dry sterile dressing change for an abdominal wound. In which direction should the nurse use a swab to clean?

The nurse is taking care of a post-surgical patient and notes the incision is clean and dry, with sutures intact. The nurse further assesses that the wound is healing by:

What type of dressing allows for multiple inspections and changes without disrupting the skin because the tape is left in place?