NCLEX · Basic Care and Comfort

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

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 Dry gauze dressing
  2. B 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)
  3. C Wet-to-dry dressing
  4. D Leave open to air

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