NCLEX-RN practice › Basic Care and Comfort
NCLEX question: staging a deep tissue pressure injury
Basic Care and Comfort · Multiple choice · Clinical judgment step: Analyze cues
Client record
Skin assessment
- Location
- sacrum
- Skin
- intact
- Color
- deep maroon-purple, does not blanch
- Texture
- boggy, warmer than surrounding skin
- Size
- 5 × 4 cm
Client reports pain at the site
The nurse assesses the sacrum of a client who was in the emergency department on a stretcher for 14 hours. Which classification should the nurse document?
- A. Deep tissue pressure injury
- B. Stage 2 pressure injury
- C. Unstageable pressure injury
- D. Stage 1 pressure injury
Show the answer and rationales
Answer: A
Deep tissue pressure injury: intact or nonintact skin with persistent nonblanchable deep red, maroon or purple discolouration. It may rapidly evolve into a full-thickness wound.
- A. Correct. Correct. Intact skin with persistent nonblanchable deep red, maroon or purple discolouration and boggy, painful tissue indicates damage to underlying soft tissue from pressure and shear.
- B. Incorrect. Stage 2 has partial-thickness skin loss with exposed dermis; this skin is intact.
- C. Incorrect. Unstageable describes full-thickness loss obscured by slough or eschar, not intact skin.
- D. Incorrect. Stage 1 is nonblanchable erythema of intact skin without purple or maroon discolouration.
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