NCLEX Exam Practice Question of the Week - 3/7/12

Elsevier NCLEX Exam Review

Question: An older adult client has an open wound over the coccyx that extends through the dermis and subcutaneous tissue, exposing the deep fascia. The wound edges are distinct, and the wound bed is a pink-red color. There is no bruising or sloughing. What stage of pressure ulcer is this wound?

1 Stage I
2 Stage II
3 Stage III
4 Stage IV

Answer: 3

Rationale: This is classified as a stage III pressure ulcer because of the full-thickness tissue loss extending to the deep fascia. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling. A stage I pressure ulcer is characterized by intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. A stage II pressure ulcer is characterized by partial-thickness loss of dermis presenting as a shallow, open ulcer with a red-pink wound bed without slough, which may also present as an intact or open/ruptured serum-filled blister. A stage IV pressure ulcer is characterized by full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling.

This week’s NCLEX exam practice question came from:

Zerwekh: Illustrated Study Guide for the NCLEX-RN Exam, 7th Edition, Chapter 11, pg 212, question 6

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