Difficulty: Medium
Average Score: 88%
Simulated
The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:
Correct answer
B
Rationale
White skin around the wound edges suggests nonviable tissue (maceration or necrosis), which may require surgical debridement. Excessive moisture could contribute but is not the primary issue, turning/positioning is preventive, and this is not a normal healing sign.