Certified Medical-Surgical Registered Nurse Practice Exam

What stage pressure ulcer is characterized by visible subcutaneous fat but no exposure of bone, tendon, or muscle?

1. Stage II

2. Suspected deep tissue injury

3. Stage III

4. Stage IV

The correct answer is: Stage III

The correct choice reflects that a Stage III pressure ulcer is characterized by full-thickness tissue loss, where subcutaneous fat may be visible, but there is no exposure of bone, tendon, or muscle. This distinction is important for identifying the severity of the ulcer and determining the appropriate treatment. In a Stage II pressure ulcer, there is partial-thickness loss of the dermis presenting as a shallow open wound, which does not include visible subcutaneous fat. Suspected deep tissue injury is indicative of localized damage to the underlying tissue, often appearing as a bruised area but does not provide evidence of visible fat or tissue loss. Stage IV pressure ulcers are more severe, involving full-thickness tissue loss with exposure of bone, tendon, or muscle, which is not applicable in this case as we are specifically noting the absence of such exposure.