answers 2026\2027 A+ Grade
Stage 1 pressure ulcer
- correct answer Intact skin with nonblanchable redness
Stage 2 pressure ulcer
- correct answer Partial loss of dermis. Shallow open ulcer, usually shiny, or dry. Red-pink wound bed
without sloughing or bruising.
Stage 3 pressure ulcer
- correct answer Full thickness tissue loss, subcutaneous fat may be visible. Possible undermining and
tunneling.
Stage 4 pressure ulcer
- correct answer Full thickness tissue loss with exposed bone, tendon,or muscle. Slough or eschar may
be present as well as undermining and tunneling.
Unstageable pressure ulcer
- correct answer Full thickness tissue loss, wound base covered by slough and eschar therefor dull depth
cannot be determined.
Slough
- correct answer Fibrous tissue in wound bed that can be yellow, tan, gray, green, or brown.
Nursing interventions to prevent pressure unlcers
- correct answer Reposition bed bound pt every two hours, instruct pt in wheelchair to shift their weight
every hour. Use of cushions and barrier cream. Manage moisture, optimize nutrition and hydration.