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 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.

A. Prepare a discard bag next to the wound. B. Remain very still during the procedure. C. Restrain from moving the patient. D. Change gloves after removing the old dressing.

Correct Answer is D

Explanation

Choice A rationale
Preparing a discard bag next to the wound is a practical step in the process, but it is not the most critical action to prevent infection.

Choice B rationale
Remaining very still during the procedure is important, but it does not directly relate to maintaining the sterility of the dressing change.

Choice C rationale
Restraining from moving the patient is not typically necessary unless the patient is at risk of causing harm to themselves or disrupting the procedure.

Choice D rationale
Changing gloves after removing the old dressing is crucial to maintain sterility. The old dressing may be contaminated, and fresh gloves reduce the risk of introducing bacteria to the clean wound.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

When preparing to change a sterile dressing over an incision, it is most important to remember to:

Correct Answer is D

Explanation

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