# Drag each assessment finding to the pressure-injury category it most strongly supports. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568367&lang=en > language: en > subject: System-Specific Assessments > category: ROR ## Question Drag each assessment finding to the pressure-injury category it most strongly supports. **1.** Shallow open ulcer with a pink-red wound bed and no slough Select a category Stage 2 Stage 3 Unstageable **2.** Intact serum-filled blister on the heel Select a category Stage 2 Stage 3 Unstageable **3.** Full-thickness tissue loss with visible subcutaneous fat Select a category Stage 2 Stage 3 Unstageable **4.** Undermining and tunneling with visible adipose tissue Select a category Stage 2 Stage 3 Unstageable **5.** Deep crater with visible fat but no exposed muscle Select a category Stage 2 Stage 3 Unstageable **6.** Wound bed completely covered by thick eschar Select a category Stage 2 Stage 3 Unstageable **7.** Full-thickness tissue loss with slough obscuring the base Select a category Stage 2 Stage 3 Unstageable ## Explanation Stage 1 is intact skin with nonblanchable erythema. Stage 2 is partial-thickness skin loss with exposed dermis. Stage 3 is full-thickness skin loss with visible adipose but no exposed fascia, muscle, tendon, cartilage, or bone. Unstageable injury has obscuring slough or eschar. Deep-tissue pressure injury has persistent deep red, maroon, or purple discoloration or a dark wound bed. In this set, only three categories are used: Stage 2, Stage 3, and Unstageable. Findings that describe intact skin or deep-tissue discoloration are not included. Items with partial-thickness loss or exposed dermis belong to Stage 2; items with visible adipose or full-thickness loss belong to Stage 3; items with obscured wound beds belong to Unstageable. ## In-depth explanation Quick answer Stage 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 correct Pressure 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 picture Accurate 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 hook Stage 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 rule Assign 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 wrong Findings 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 ## Clinical scenario A nurse is reviewing skin assessment findings for several patients. For each finding, select the pressure-injury category that is best supported by the available clinical information. Use the visible tissue, skin integrity, color, and whether the wound bed is obscured. Do not estimate a deeper stage through slough or eschar. ## Key concepts - **Stage 2 pressure injury** — Partial-thickness skin loss with exposed dermis; wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister. - **Stage 3 pressure injury** — Full-thickness skin loss with visible adipose tissue; granulation tissue and epibole may be present; undermining and tunneling may occur. - **Unstageable pressure injury** — Full-thickness skin loss in which the wound bed is completely covered by slough or eschar, preventing determination of the true depth. ## Related questions - [A nurse on a medical-surgical unit reviews the morning labs for a 67-year-old male client …](https://mymerci.kr/pages/nclex_q.php?qn_id=361711&lang=en) - [A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following ton…](https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=en) - [A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit…](https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=en) - [A 72-year-old male client is receiving a continuous IV heparin infusion for a left lower-e…](https://mymerci.kr/pages/nclex_q.php?qn_id=362064&lang=en) - [A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. 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