Practice Quiz

CCRN Critical Care Nursing

Category - Adult

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The nurse is assessing her patient for pressure ulcers. On the patient’s right heel, she notices one inch by ½ inch red shallow crater with a small amount of white drainage, surrounded by bright pink skin. She documents this finding as a:
  1. Blanchable, stage one pressure ulcer.
  2. Stage 2 partial thickness wound.
  3. Stage 3 full thickness wound.
  4. Non stageable wound.
Explanation
Answer: B - The nurse would document the pressure ulcer on the heel as a stage 2 partial thickness pressure ulcer. It involves two layers of the skin- the epidermis and the dermis with a shallow crater that breaks through the first layer of skin.
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