Difficulty: Medium
Average Score: 75%
Simulated
The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document?
Correct answer
C
Rationale
Stage III pressure ulcer is full-thickness skin loss that extends to the subcutaneous fat, but not fascia; bone, tendon, and muscle are not visible. Stage I is intact but red and nonblanching. Stage II involves a break in the skin with partial-thickness loss. Stage IV is full-thickness loss with exposed muscle and bone.