Certified Medical-Surgical Registered Nurse Practice Test

In this case, the correct answer is Stage III pressure ulcer. A Stage III pressure ulcer involves full-thickness tissue loss where subcutaneous fat is visible but bone, tendon, and muscle are not exposed. There may be some slough present that does not obscure the depth of tissue loss. Additionally, there may be undermining and tunneling present in a Stage III pressure ulcer. Option A, Stage II, involves partial-thickness skin loss involving the epidermis and/or dermis but not extending below the dermis. Option B, Suspected deep tissue injury, typically presents as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Option D, Stage IV, involves full-thickness tissue loss with exposed bone, tendon, or muscle, and often with undermining and tunneling.