A nurse is assisting with the care of a client who has an infected wound with significant exudate.
Which of the following dressings should the nurse plan to cover the client's wound?

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

E.

Choice A rationale:

A BMI of 20 is within the normal range (18.5-24.9), so it does not increase the risk of a pressure injury.

Choice B rationale:

Peripheral neuropathy can lead to a loss of sensation, which increases the risk of a pressure injury as the individual may not feel discomfort or recognize the need to reposition.

Choice C rationale:

Immobility is a major risk factor for pressure injuries as it increases pressure on certain areas of the body, reducing blood flow and leading to tissue damage.

Choice D rationale:

Hypoperfusion, or reduced blood flow, can lead to tissue hypoxia and increase the risk of pressure injuries.

Choice E rationale:

A prealbumin level of 16 mg/dL is at the lower end of the normal range (15-36 mg/dL)2. Low prealbumin levels can indicate poor nutritional status, which is a risk factor for pressure injuries.