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

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

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About this topic: Basic Care and Comfort

Basic care and comfort questions cover mobility, positioning, nutrition, elimination, hygiene, sleep and comfort measures, and the assistive devices and complementary therapies that support them. This is one of 6 RN: Physiological Integrity questions on basic care and comfort, each with a full explanation on a single study page.

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