The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure injuries.The nurse has become competent in the care of pressure wounds and recognizes that which of the following is a staged pressure injury that does not require a dressing?

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Stage 1 intact pressure injuries that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing.This allows visual inspection and monitoring.A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture.A composite film,hydrocolloid,or hydrogel can be utilized on a clean stage 2 pressure injury.A hydrocolloid,hydrogel covered with foam,calcium alginate,gauze,and growth factors can be utilized with a clean stage 3 injury.Hydrogel,calcium alginate,gauze,and growth factors can be utilized with a clean stage 4 injury.For an unstageable wound covered with eschar,the nurse should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.In rare cases when eschar is dry and intact,no dressing is used,but this is an unstaged pressure injury.

The Nurse Is Staffing a Medical-Surgical Unit That Is Assigned