A nurse is concerned about an HIV immunocompromised patient’s ability to heal due to a lack of certain factors. Which of the following are necessary for proper wound healing? (Select all that apply.)

Choice A rationale

A wound at Stage 1 is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The skin remains unbroken with persistent redness that does not turn white when pressed. This stage indicates that the epidermis is closed.

Choice B rationale

Stage 2 involves partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. This stage is not applicable if the epidermis is closed.

Choice C rationale

Stage 3 is defined by full-thickness skin loss, where fatty tissue is visible in the wound, and granulation tissue and epibole (rolled wound edges) are often present. This stage indicates a more severe wound than what is described in the scenario.

Choice D rationale

Stage 4 represents full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. The condition described does not match the severity of a Stage 4 wound.

Choice A rationale
Tegaderm or Opsite dressings are transparent and adhesive, allowing for wound inspection without removal, but they do not involve tape that remains in place for multiple changes.

Choice B rationale
Abdominal pads held in place with paper tape would require the tape to be removed and replaced with each dressing change, which can disrupt the skin.

Choice C rationale
The term ‘retention’ is incomplete and does not specify a type of dressing. Retention typically refers to the ability to keep something in place, such as a dressing, but does not imply that the tape remains in place.

Choice D rationale
Montgomery straps are designed with ties that attach to an adhesive base that remains on the skin. This allows the dressing to be changed without removing and reapplying tape, thus preventing skin disruption.