NCLEX · Basic Care and Comfort

A client has a Stage 2 pressure injury on the sacrum. What is the most appropriate nursing intervention?

Correct answer

Keep the area clean and dry, use appropriate dressings (e.g., hydrocolloid or foam), reposition every 2 hours, address nutrition and moisture

  1. A Massage the area to improve circulation
  2. B Keep the area clean and dry, use appropriate dressings (e.g., hydrocolloid or foam), reposition every 2 hours, address nutrition and moisture
  3. C Apply heat continuously
  4. D Use only saline gauze with daily changes

Why this is the answer

Pressure injury staging (NPIAP): Stage 1 — intact skin with non-blanchable redness; Stage 2 — partial-thickness skin loss with exposed dermis (looks like a shallow open ulcer, blister, or abrasion); Stage 3 — full-thickness skin loss exposing subcutaneous fat; Stage 4 — full-thickness with exposed bone, tendon, or muscle; Unstageable — full-thickness with eschar or slough obscuring depth; Deep Tissue Injury — intact or non-intact skin with persistent purple/maroon discoloration. Management principles for Stage 2: clean the wound (saline or commercial wound cleanser, not hydrogen peroxide which is cytotoxic); choose appropriate dressing (hydrocolloid for moist wound healing in clean wounds, foam for absorption, transparent film for shallow wounds); reposition every 2 hours; use pressure-redistribution surfaces (alternating pressure mattresses); manage moisture (incontinence care); optimize nutrition (protein, vitamin C, zinc); avoid friction and shear. Never massage pressure injuries — causes more tissue damage.
Source: NCLEX-RN, Basic Care — Pressure Injuries