Difficulty: Medium
Average Score: 65%
Simulated
The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm X 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?
Correct answer
D
Rationale
A full-thickness wound with black collagen (eschar) is unstageable (D) because the depth cannot be assessed. Stage I (A) is non-blanchable redness, Stage II (B) is partial thickness, and Stage III (C) is full thickness without eschar.