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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-thickness
skin 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, subcutaneous
fat 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 an
ulcer 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 essential
to accurately complete the first step in assessment—inspection—and the entire
assessment process. Natural light or a halogen light is recommended. Fluorescent
light sources can produce blue tones on darkly pigmented skin and can interfere
with an accurate assessment. Other items that could possibly be used during the
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assessment include gloves for
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