HESI FUNDAMENTALS PROCTORED EXAM

1. The nurse is admitting an older patient from a nursing home. During the

assessment, the nurse notes a shallow open reddish, pink ulcer without slough on

the right heel of the patient. How will the nurse stage this pressure ulcer?

a. Stage I

b. Stage II

c. Stage III

d. Stage IV

ANS: B

This would be a Stage II pressure ulcer because it presents as partial-thickness

skin loss involving epidermis and dermis. The ulcer presents clinically as an

abrasion,...