A nurse documents a paralyzed client's right heel ulcer as a stage 3 pressure wound.
Which statement describes a stage 3 pressure wound?
A) Pressure-related alteration of intact skin
B) Loss of epidermis with damage into the dermis that appears as a shallow crater/blister with red/pink wound bed and no sloughing
C) Subcutaneous tissues involved and subcutaneous fat may be visible with no bone, tendon, or muscle exposed
D) Extensive damage to underlying structures, full-thickness tissue loss with exposed bones, tendons, or muscles
Correct Answer:
Verified
Q1: A nurse is assessing the wound in
Q2: A nurse is assessing the wound in
Q3: A nurse documents in the electronic medical
Q4: What is the common cause of skin
Q5: What stage pressure wound is characterized by
Q7: What measurements are included as part of
Q8: Which factors contribute to skin breakdown? Select
Q9: What nursing considerations should be kept in
Q10: What nursing measures should be implemented to
Q11: What pressure-reducing technique will have the greatest
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