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