The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.

B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.

C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.

D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.

A. Relying on recall of information from past lectures and textbooks. Critical thinking involves applying knowledge, not just recalling it. Nurses must analyze patient-specific data and adapt care accordingly.

B. Using the nursing process. The nursing process (assessment, diagnosis, planning, implementation, evaluation) is a structured approach that guides clinical decision-making and ensures patient-centered care.

C. Drawing on past clinical experiences to formulate standardized care plans. Past experiences can inform decision-making, but care plans must be individualized to the patient’s current condition rather than relying solely on standardization.

D. Depending on the charge nurse to determine priorities of care. While charge nurses provide leadership, each nurse is responsible for critical thinking and independent decision-making based on their assessment.