A nurse is auditing pressure injury documentation on a medical unit. Each entry lists the wound findings and the classification that was charted. Which charted classifications are accurate? Select all that apply.

Quick answer
Options 3, 4, and 6 are accurate. The heel, gluteal-cleft, and ischial entries each mislabel a near-neighbour category.

Why this is correct
Stage 2 is partial-thickness loss with a viable pink or red moist dermal bed and no slough. Pressure injuries on mucous membranes (often from devices such as cannulas or tubes) cannot be staged because mucosa has no layers matching skin anatomy. Stable, dry, adherent eschar on a heel means the depth cannot be seen, so the injury is unstageable and the eschar is usually left in place.

Easy analogy or mental picture
Think of staging as measuring the depth of a hole: you can only number the hole when you can see its floor (unstageable if covered), when the surface is really skin (mucosa is not staged), and when pressure, not wetness, dug it.

Memory hook
Maroon and boggy = deep tissue. Wet and diffuse = moisture, not pressure. Fat plus tunnel = still Stage 3; bone, tendon, or muscle = Stage 4.

NCLEX decision rule
Before accepting a stage, ask three questions: Is it skin? Can I see the base? Is the cause pressure? Then match the deepest visible tissue, not the size, drainage, or tunneling.

Why the other choices are wrong
Heel maroon area (option 5): tempting because the skin is intact like Stage 1, but a purple or maroon, boggy, non-blanchable area signals deep tissue pressure injury, which can evolve rapidly. Gluteal-cleft erosions (option 2): tempting because they are shallow like Stage 2, but diffuse, irregular erosions from incontinence are incontinence-associated dermatitis, a moisture problem, and NPIAP advises against calling it Stage 2. Ischial wound (option 1): tempting because tunneling looks deep, but the stage is set by the deepest visible tissue; with fat and no bone, tendon, or muscle, it is Stage 3.