NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions Questions
Extract:
Question 1 of 5
A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?
Correct Answer: B
Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage.
Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin.
Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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