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1. The nurse is admitting an older patient from a nursing home. During the assessment,
the nurse notes a shallow open reddish, pink ulcer without slough on
the right heel of the patient. How will the nurse stage this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thicknessskin loss
involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or
shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence.
With a Stage III pressure ulcer, subcutaneousfat may be visible, but bone, tendon, and muscles
are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or
muscle.
2. The nurse is completing a skin assessment on a patient with darkly
pigmented skin. Which item should the nurse use first to assist in staging anulcer on this
patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essentialto accurately
complete the first step in assessment—inspection—and the entire assessment process. Natural
light or a halogen light is recommended. Fluorescentlight sources can produce blue tones onÂ
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