Certified Nurses Operating Room (CNOR) Practice Exam

What characterizes Stage II pressure ulcer?

1. Intact skin with redness

2. Partial thickness loss of skin

3. Full thickness skin loss

4. Slough and eschar present

The correct answer is: Partial thickness loss of skin

Stage II pressure ulcers are characterized by a partial thickness loss of skin that presents as a shallow open ulcer, which may appear as a blister or an erosion. The skin loss involves the epidermis and may extend into, but not through, the dermis. This stage signifies a more advanced level of tissue damage compared to Stage I, where the skin remains intact but shows signs of redness and may feel warmer or cooler than the surrounding tissue. In the context of this question, the correct identification of Stage II as involving partial thickness skin loss is essential for prevention and treatment strategies. Recognizing the features of Stage II helps healthcare providers implement appropriate interventions to promote healing and prevent progression to more severe stages of pressure ulcers, such as full thickness skin loss or the presence of necrotic tissue which would be indicative of Stage III or IV ulcers. Understanding these distinctions assists in effective wound assessment and management protocols in the operating room and other healthcare settings.