Certified Nurses Operating Room (CNOR) Practice Exam

Which of the following is the best description of a suspected deep tissue pressure ulcer?

1. Intact skin with nonblanchable redness

2. Blood-filled blister

3. Full thickness with exposed bone

4. Yellow slough with eschar

The correct answer is: Blood-filled blister

A suspected deep tissue pressure ulcer is characterized by localized areas of discoloration due to damage of underlying soft tissue, typically presenting as a blood-filled blister. This type of ulcer occurs when there is sustained pressure that causes damage to the tissue beneath the skin, often without the initial surface skin showing significant changes. In this context, a blood-filled blister signifies the acute changes in the tissue structure. This can indicate a more serious injury that may have developed due to factors such as prolonged pressure, friction, or shear, often complicating quick diagnosis until the condition evolves. The other options represent different types of pressure ulcers or skin damage. Intact skin with nonblanchable redness suggests an early stage pressure injury but does not necessarily indicate deep tissue damage. Full thickness with exposed bone describes a more advanced and severe ulcer that has progressed beyond the deep tissue stage. Yellow slough with eschar indicates existing slow-healing wounds and potential necrosis but do not pertain specifically to the initial classification of a suspected deep tissue pressure ulcer.