Which clinical indicator does the nurse use to assess a stage II pressure ulcer?
1. Deep, open crater
2. Persistent redness
3. Boggy consistency
4. Superficial blistering
4
4. A stage II pressure ulcer is a superficial, partial-thickness skin loss presenting as an abrasion, blister, or shallow crater.
1. A deep crater is consistent with clinical indicators for a stage III or IV ulcer.
2 and 3. Persistent redness and a boggy or firm consistency are characteristic of a stage I pressure ulcer.
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