Quick answerStage 2: shallow open ulcer with a pink-red wound bed and no slough; intact or ruptured serum-filled blister. Stage 3: full-thickness tissue loss with visible subcutaneous fat; undermining and tunneling may be present. Unstageable: full-thickness tissue loss with wound bed completely covered by slough or eschar; depth cannot be determined until debridement.
Why this is correctPressure injury categories are defined by the deepest visible tissue layer and whether the wound bed is obscured. Stage 2 involves partial-thickness loss with exposed dermis; Stage 3 involves full-thickness loss with visible adipose; Unstageable involves full-thickness loss with an obscured wound bed. The selected findings match these definitions.
Clinical pictureAccurate staging guides prevention and treatment. Misclassifying a Stage 2 as Stage 3 may lead to unnecessary debridement or inappropriate dressing selection. Misclassifying an unstageable injury as Stage 3 may underestimate tissue damage and delay appropriate offloading or debridement.
Memory hookStage 2 = partial thickness, dermis visible, no adipose. Stage 3 = full thickness, adipose visible, no deeper structures. Unstageable = full thickness, wound bed obscured by slough or eschar.
NCLEX decision ruleAssign the category based on the deepest visible tissue and whether the wound bed is obscured. Do not stage through slough or eschar.
Why the alternatives are wrongFindings of intact skin with nonblanchable erythema would be Stage 1; findings of exposed tendon, muscle, or bone would be Stage 4; findings of persistent deep red, maroon, or purple discoloration would be Deep-tissue pressure injury. These are not included in this set.
Sources
1NCSBN 2026 NCLEX-RN Test Plan
2National Pressure Injury Advisory Panel staging definitions