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