Question

During the shift report, a nurse is told that a patient she will be caring for has a stage II pressure ulcer. What should the nurse expect to visualize during the dressing change?

a. Ulcer that appears black with possible signs of infection
b. Shallow ulcer that appears blistered, cracked, or abraded
c. Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base
d. Redness of skin with no ulceration

Answer 1

During the dressing change of a stage II pressure ulcer, the nurse should visualize a craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base.

Step-by-step explanation:

The nurse should expect to visualize a craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base during the dressing change of a stage II pressure ulcer. In this stage, the ulcer is deeper and extends into the dermis. It appears as an open sore or shallow ulcer with a red or pink base.