Editing Anatomy and Physiology – LPN Practice Questions (section)

==Question 3==
A licensed practical nurse is repositioning an immobile older adult and observes an area of nonblanchable redness over the sacrum with the skin intact. How should the nurse describe and act on this finding?
# A stage 1 pressure injury; reposition off the area and report the finding to the registered nurse.
# A stage 2 pressure injury; apply a dry sterile dressing and continue care.
# A normal finding from lying supine; no action is needed.
# A stage 3 pressure injury; document the depth and measure the wound.

'''Answer:''' 1 (A). A stage 1 pressure injury; reposition off the area and report the finding to the registered nurse.

''Rationale:'' A stage 1 pressure injury is intact skin with localized nonblanchable erythema, meaning the redness does not fade with fingertip pressure because capillaries in the dermis have been damaged. Immediate pressure relief and prompt reporting allow a plan of care to be started before tissue loss occurs. Option 2 is incorrect because a stage 2 injury involves partial thickness loss of the epidermis and dermis, often appearing as an open shallow ulcer or an intact or ruptured blister. Option 3 is incorrect because normal blanchable redness fades within minutes of pressure relief. Option 4 is incorrect because stage 3 involves full thickness loss with visible subcutaneous fat.