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 on