The nurse is caring for a client in the long-term care facility that was living in their home with a family member caring for them
The family member states that they had a difficult time getting the client to eat or drink and he developed a "bed sore." The nurse observes a serous drainage covering the dressing and a 2 × 2 cm crater that is 0.5 cm deep. What stage does the nurse document this pressure sore as? A) Stage I
B) Stage II
C) Stage III
D) Stage IV
C
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Stage III has superficial skin impairment that progresses to a shallow crater that extends to the subcutaneous tissue. Stage I pressure sores are characterized by redness of intact skin. The reddened skin of a beginning pressure sore fails to resume its normal color, or blanch when pressure is relieved. Stage II is the same as stage I but has a blister or shallow break in the skin. Stage IV has tissue damage that is deeply ulcerated, exposing muscle and sometimes bone.
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