Difficulty: Medium
Average Score: 70%
Simulated
When doing the client's skin assessment the nurse notes a 3 cm area of partial thickness skin loss that looks like a blister on the client's sacral area. The nurse consults the wound care nurse who stages the wound as a pressure ulcer.
Correct answer
B
Rationale
The correct answer is B: Stage II. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a blister or shallow open wound. In this scenario, the nurse noted a 3 cm area of partial thickness skin loss resembling a blister on the sacral area, which aligns with the characteristics of a Stage II pressure ulcer. The other choices are incorrect because a Stage I pressure ulcer involves intact skin with non-blanchable redness, Stage III involves full-thickness skin loss extending into the subcutaneous tissue, and Stage IV involves full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures.