Practice Question
A nurse is caring for a client that is immobile. The nurse recognizes that the appearance of non-blanchable erythema on the heels most likely indicates which of the following stages of pressure injuries?
Answer Choices:
Correct Answer:
Stage I pressure injury
Rationale:
🟪 Stage I pressure injury is identified by non-blanchable erythema of intact skin, commonly over bony prominences such as the heels.
🟪 The skin remains intact, but redness does not fade when pressure is applied, indicating early tissue damage.
🟪 This stage reflects impaired capillary blood flow caused by sustained pressure in an immobile client.
🟪 Early recognition at this stage allows for prompt pressure relief and repositioning to prevent progression.
🟪 Identifying Stage I injuries is critical because they are reversible with timely nursing interventions.
Stage IV pressure injury
🟪 Stage IV involves full-thickness skin and tissue loss with exposed muscle, tendon, or bone.
🟪 Non-blanchable erythema alone does not meet criteria for this advanced stage.
Stage II pressure injury
🟪 Stage II presents with partial-thickness skin loss, such as an open blister or shallow ulcer.
🟪 Intact skin with redness indicates an earlier stage.
Stage III pressure injury
🟪 Stage III involves full-thickness skin loss without exposed bone or muscle.
🟪 Visible tissue loss must be present, which is not seen with simple erythema.
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This question is from RN NTEGUMENTARY which contains 46 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Fundamentals
- Answer Choices: 4