ATI RN
ATI Fundamentals Exam Special Unit ADN Questions
Extract:
Question 1 of 5
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?
Correct Answer: D
Rationale: The correct answer is D: Stage II. A Stage II pressure ulcer is characterized by a shallow open ulcer without slough, like the one described on the patient's right heel. In this stage, the skin is broken, exposing the underlying tissue. The absence of slough differentiates it from more severe stages.
Choice A, Stage IV, involves extensive tissue damage, including muscle and bone, which is not present in this case.
Choice B, Stage I, describes non-blanchable erythema, not an open ulcer.
Choice C, Stage III, involves full-thickness tissue loss with visible fat, which is more severe than the presentation described.
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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