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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
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