NR 224 EXAM 2 LATEST 3 VERSIONS (VERSION A, B & C)
ACTUAL EXAM 250 QUESTIONS AND CORRECT DETAILED
ANSWERS
What is a stage 1 Pressure ulcer called? - ANSWER: - Non-blanchable erythema
What are the characteristics of a stage 1 pressure ulcer? - ANSWER: - intact skin
- non-blanchable redness
What are some characteristics of stage 1 pressure ulcers in dark pigmented skin? -
ANSWER: - areas of skin my not have visible blanching
- color may differ from surrounding areas
What is a stage II pressure ulcer called? - ANSWER: - partial-thickness skin loss
What layer of the skin are exposed with stage II pressure ulcers? - ANSWER: - dermis
is exposed
What layer of the skin is lost in a stage II pressure ulcer? - ANSWER: - epidermis
What are some characteristics of a stage II pressure ulcer? - ANSWER: - Shallow
wound
- open wound
- wound looks red/ pink
- no slough presented
What other aspects may a stage II pressure ulcer look like? - ANSWER: - intact
wound
- ruptured serum-filled blister
What does the wound bed look like with a stage II pressure ulcer - ANSWER: -
Resembles a crater
What is a stage III pressure ulcer called? - ANSWER: - Full-thickness skin loss
What two aspects may be noted as visible in a stage III pressure ulcer? - ANSWER: -
Sloughing
- Eschar
What does the wound bed look like in stage III pressure ulcer? - ANSWER: - deep
wound bed
What are some characteristics of a stage III pressure ulcer? - ANSWER: - Exposure of
the subcutaneous fat
- slough
, - eschar
- tunneling
- undermining
What aspects of the wound bed can be noted with a stage III pressure ulcer? -
ANSWER: - tunneling may be noted with a stage III P.U.
- Undermining may be noted w/ a stage III P.U.
What is a stage IV pressure ulcer called? - ANSWER: - full-thickness and tissue loss
What are some characteristics of a stage IV pressure ulcer? - ANSWER: - exposed
tendon or muscle
- exposure of bones
- slough
- eschar
- undermining
- tunneling
What can be noted in stage III and stage IV of pressure ulcers? - ANSWER: All the
below can be noted:
- tunneling
- eschar
- undermining
- slough
What are some characteristics of a suspected deep tissue injury? - ANSWER: - purple
or maroon localized area of discoloration
- blood-filled blister
What can an area of a suspected deep tissue injury area feel like? - ANSWER: -
painful
- mushy
- boggy
- firm
- warmer and/or cooler than adjacent tissue
What is a unstageable pressure ulcer? - ANSWER: - Full-thickness tissue loss in
which the base of the ulcer is covered by eschar or other characterizations
What are some skin discolorations that classify as eschar? - ANSWER: - tan
- brown
- black
What are some other skin discoloration that can lead to a diagnosis of an
unstageable pressure ulcer? - ANSWER: - yellow
- tan
- gray
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