ATI RN
ATI Nursing 100 Day Exam 4 Fundamentals Questions
Extract:
Question 1 of 5
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.
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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