What stage is a wound if the epidermis is closed and has unblanchable redness?

Stage 1

Stage 2

Stage 3

stage 4

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

Choice A rationale
The second stage of wound healing is proliferation, which occurs after the initial hemostasis phase. During proliferation, the wound begins to be rebuilt with new, healthy granulation tissue. This tissue is rich in collagen, which forms a foundation for new tissue growth. Capillaries grow across the wound, bringing oxygen and nutrients that are essential for healing. New skin cells begin to form over this granulation tissue, which is a critical component of the healing process.

Choice B rationale
Maturation is the third and final stage of wound healing. It follows the proliferation stage and involves the remodeling of collagen, which strengthens the tissue and restores its normal function. During maturation, the new tissue slowly gains strength and flexibility. Here, the collagen fibers reorganize, the tissue remodels and contracts, and the healed wound becomes more resilient. This stage can take a long time, sometimes up to a year or more, depending on the wound’s severity and the patient’s overall health.

Choice C rationale
Inflammation is indeed the second stage of wound healing. It is a natural part of the healing process and involves controlling bleeding, preventing infection, and enabling the migration of healing cells to the wound area.

Choice D rationale
Remodeling is the last stage of wound healing, not the second. It occurs after the wound has closed and involves the long-term strengthening and formation of scar tissue.

A. Excessive gas B. Complaint of constipation C. Increased drainage from the wound D. Increased pallor of the surgical site

Correct Answer is C

Explanation

Choice A rationale
Excessive gas is not typically an indication of wound dehiscence. While it may cause discomfort, it does not suggest that the wound layers have separated.

Choice B rationale
A complaint of constipation is a common postoperative concern due to decreased mobility and use of narcotics but is not a sign of wound dehiscence.

Choice C rationale
Increased drainage from the wound, especially if the fluid is clear or serous, can be an early sign of dehiscence, indicating that the wound layers are separating and fluid is accumulating.

Choice D rationale
Increased pallor of the surgical site might indicate poor perfusion but is not a direct sign of dehiscence. Dehiscence would more likely show signs of inflammation or unusual discharge.

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What stage is a wound if the epidermis is closed and has unblanchable redness?

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Naxlex Comprehensive Predictor Exams

The nurse clarifies that the second stage of wound healing is:

Correct Answer is A

Explanation

The nurse is alert to the indication of possible dehiscence of an abdominal surgical wound, which would be evidenced by:

Correct Answer is C

Explanation

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.)

A patient is incontinent on the first day after surgery. This is a risk factor for the development of skin breakdown and infection primarily because:

The nurse warns the patient that one of the patient’s habits has caused the reduction of functional hemoglobin, which limits the hemoglobin’s oxygen-carrying ability. To improve this situation, the nurse suggests that the patient quit:

A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?

Chronic wounds that are not healing well may benefit from (Select all that apply):

What stage is a wound if the epidermis is closed and has unblanchable redness?

The patient entered the hospital with a reddened area that does not blanch with pressure over the left hip. He states that it is painful. This is indicative of which stage of pressure injury?

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?