NCLEX Practice Test

What is the stage of a shallow open area with a clean dark pink wound bed about 1 cm in diameter, where the surrounding area is slightly hard and warm to touch with erythema?

1. Stage 1

2. Stage 2

3. Stage 3

4. Stage 4

The correct answer is: Stage 1

The correct answer is based on the characteristics of the wound described. A stage 1 pressure injury is identified by non-blanchable erythema of intact skin, which can sometimes appear slightly warm, hard, or swollen. The presence of a clean dark pink wound bed indicates that there might not be an open area, but rather, some irritation or initial damage is starting to take place. In this scenario, the dimensions of the wound (1 cm in diameter) and the surrounding erythema suggest early skin involvement without loss of tissue, which aligns more closely with stage 1 rather than deeper, more extensive tissue damage seen in other stages. In contrast, stages 2, 3, and 4 involve varying degrees of skin loss, from partial thickness (stage 2) to full thickness involving underlying tissues (stages 3 and 4). The characteristics given do not meet those criteria, confirming that the wound is best classified as stage 1.