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NCLEX · Basic Care and Comfort

A client has a stage 2 pressure injury on the sacrum. Which dressing is most appropriate?

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Correct answer

Hydrocolloid dressing — maintains a moist wound environment that promotes epithelial migration, is self-adhesive, requires less frequent changing, and protects the wound from contamination; appropriate for stage 2 wounds (partial-thickness skin loss)

  1. A Leave open to air
  2. B Dry gauze dressing
  3. C Hydrocolloid dressing — maintains a moist wound environment that promotes epithelial migration, is self-adhesive, requires less frequent changing, and protects the wound from contamination; appropriate for stage 2 wounds (partial-thickness skin loss)
  4. D Wet-to-dry dressing

Why this is the answer

PRESSURE INJURY STAGING AND DRESSING SELECTION:

Stage 2: Partial thickness skin loss — epidermis and part of dermis; wound appears as shallow open ulcer with red-pink wound bed.

Moist wound healing: Evidence consistently shows moist wound healing accelerates epithelialisation compared to dry.

Dry gauze: Creates a dry environment, adheres to wound bed, traumatises healing tissue on removal — NOT appropriate for stage 2.

Wet-to-dry: Appropriate for debridement of necrotic tissue (stage 3-4) — mechanically removes tissue including viable; contraindicated for clean, healing wounds.

Hydrocolloid: Contains moisture, promotes healing, self-adhesive — appropriate for stage 2 without infection.

Hydrofiber/alginate: For highly exudative wounds.

Silver-containing: For infected wounds.

Pn scope: Perform wound assessment, apply ordered dressings, report changes in wound status to RN; do not independently change wound care orders.

Source: NCLEX-PN Physiological — Wound Care, Stage 2 Pressure Injury Dressing

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About this topic: Basic Care and Comfort

Basic care and comfort questions cover hygiene, mobility and positioning, nutrition and hydration, elimination, sleep, and non-pharmacological comfort measures — the daily care an LPN/LVN provides. This is one of 16 PN: Physiological Integrity questions on basic care and comfort, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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