NUR 155 Exam 3 Galen College Newest Actual Exam
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Characteristics of a stage 1 pressure ulcer - Answer-A
nonblanchable area with redness
Has minor soft tissue swelling and warmth to area
Skin is intact
Normally reversible with appropriate nursing care
Characteristics of a stage 2 pressure ulcer - Answer-
Partial thickness with loss of skin including the epidermis
and or dermis
Includes superficial wounds like cuts, blisters, or small
open areas
Wound is painful
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Ulcer is seen with reddish pinkish bed without slough or
bruising
It's superficial and can appear as a blister, or shallow
crater
Edema persists
Can become infected with pain and scant drainage
Characteristics of a stage 3 pressure ulcer - Answer-Full
thickness skin loss
Injury extends through the dermis to the underlying fascia
but does not extend through the underlying fascia
Not always a deep wound depends on location of wound
Wound base is painful
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Ulcer appears as a deep crater
Can have tunneling and undermining but not necessary to
be considered a stage 3
Drainage and infection are common
Characteristics of a stage 4 pressure ulcer - Answer-Has
full thickness skin loss with visible muscle, tendon , and or
bone present
Parts may be covered in slough or Eschar
Not usually painful due to necrosis
Deep pockets of infection may be present
Undermining and tunneling are usually present
Can be destruction , tissue necrosis , or damage to the
muscle , tendon , and bone