The nurse on the unit is going to perform wound care for her patient.
After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

Choice A rationale:

Sharp debridement involves the use of a sharp instrument or heat to remove dead tissue, which is not achieved with a hydrocolloid dressing.

Choice B rationale:

Chemical debridement involves the use of chemicals to remove dead tissue, which is not the function of a hydrocolloid dressing.

Choice C rationale:

Enzymatic debridement involves the use of enzymes to soften and remove dead tissue, which is not the function of a hydrocolloid dressing.

Choice D rationale:

Autolytic debridement uses the body’s own enzymes and moisture to soften and remove dead tissue. A hydrocolloid dressing helps maintain a moist wound environment, promoting autolytic debridement.