The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Stage IV
Stage I
Stage III
Stage II
The Correct Answer is D
A. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV.
B. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I.
C. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.
D. Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV.
B. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I.
C. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.
D. Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II.
Correct Answer is ["5"]
Explanation
1 ounce = 30 mL, so
150 mL ÷ 30 mL/oz = 5 oz
Answer: 5 ounces
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