Quick answer: The NPIAP pressure injury stages are Stage 1 (non-blanchable redness of intact skin), Stage 2 (partial-thickness loss with exposed dermis), Stage 3 (full-thickness loss with visible fat), Stage 4 (exposed or palpable bone, tendon, ligament, muscle, fascia or cartilage), unstageable (base hidden by slough or eschar) and deep tissue pressure injury (persistent maroon or purple discoloration). Mucosal injuries are not staged, and healing wounds are never reverse staged.
Pressure injury questions test three skills: naming the stage, spotting the wrong prevention step, and choosing the first action. The definitions below follow the NPIAP 2016 staging system, which the September 2026 international guideline (NPIAP, EPUAP and PPPIA) still uses. Where current guidance and the classic exam answer differ, both are given.
What are the pressure injury stages?
Stage by the deepest tissue you can see or feel. The numbers describe tissue loss, not a sequence: an injury can first appear as a stage 3.
| Stage | What you see | Exam clue |
|---|---|---|
| Stage 1 | Intact skin with localized non-blanchable erythema. Changes in sensation, temperature or firmness may come first. | Intact and stays red when pressed. Purple or maroon is not stage 1. |
| Stage 2 | Partial-thickness loss with exposed dermis: a pink or red, moist wound bed, or an intact or ruptured serum-filled blister. No fat, granulation tissue, slough or eschar. | Shallow and pink. Not used for incontinence dermatitis, skin tears, adhesive injuries or burns. |
| Stage 3 | Full-thickness skin loss with visible fat. Granulation tissue and rolled edges are common; slough, eschar, undermining or tunneling may be present. | Fat is visible, but nothing deeper. |
| Stage 4 | Full-thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. Undermining and tunneling are common. | Bone or tendon seen or felt. Watch for osteomyelitis. |
| Unstageable | Full-thickness loss with the base hidden by slough or eschar. Stable eschar (dry, adherent, intact, no redness or fluctuance) on a heel or ischemic limb is not softened or removed. | If you cannot see the base, you cannot stage it. |
| Deep tissue pressure injury (DTPI) | Intact or non-intact skin with persistent non-blanchable deep red, maroon or purple discoloration, or a blood-filled blister. Pain and temperature change often come first. | Damage starts at the bone-muscle interface and can open quickly. |
In darkly pigmented skin, blanching may not be visible, so compare the area with nearby skin for warmth, coolness, firmness and pain. For more skin integrity practice, try the integumentary practice questions.
Priority when you find a new injury: relieve pressure on the area first. Then stage it, document it, notify the provider or wound care nurse per policy, and update the plan.
What are device-related and mucosal membrane pressure injuries?
A medical device-related pressure injury is named for its cause, not its depth. It usually matches the shape of the device (oxygen tubing, a cervical collar, a nasogastric tube) and is staged like any other skin injury.
A mucosal membrane pressure injury forms on the moist lining of the respiratory, gastrointestinal or genitourinary tract, usually under an endotracheal tube, urinary catheter, gastric tube or nasal prongs. It is documented but not staged, because the skin system does not fit mucosa:
- Non-blanchable erythema cannot be seen on mucous membranes.
- Shallow mucosal ulcers look the same as full-thickness ones.
- Soft coagulum (a soft blood clot) looks like slough.
- No mucosal staging tool has proven reliable enough for clinical use.
For both, check under every device and its securement, reposition it when safe, place a preventive dressing under it if that will not affect how it works, and remove it once it is no longer needed.
Why is reverse staging not used?
Stage 3 and 4 wounds fill with granulation tissue, which never replaces the muscle, fat or bone that was lost. A shrinking stage 4 injury is documented as a healing stage 4, never as a stage 3. CMS assessment instructions say the same: do not reverse or back stage. Track progress with measurements and tissue descriptions. Even after the scar fully matures, it regains only about 80% of the original tissue’s strength, so the site stays at high risk.
How does the Braden Scale work?
The Braden Scale has six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The first five score 1 to 4 and friction and shear scores 1 to 3, so totals range from 6 to 23. A lower score means higher risk.
| Braden total | Risk level (as commonly taught) |
|---|---|
| 19-23 | Not at risk by the usual cut-off |
| 15-18 | At risk |
| 13-14 | Moderate risk |
| 10-12 | High risk |
| 9 or less | Very high risk |
Eighteen or less is the usual at-risk cut-off, but facilities can adjust it. Plan from the subscales, not just the total: a client who totals 19 but scores 1 on moisture still needs a moisture plan. Assess risk and skin as soon as possible after admission, at the interval policy sets, whenever the client’s condition worsens, and before discharge.
How do nurses prevent pressure injuries?
- Reposition on an individualized schedule. The classic exam answer for a client who cannot turn is at least every 2 hours. The 2026 guideline supports 2- or 3-hour intervals for most at-risk clients on a pressure-redistributing mattress and advises against routinely stretching to 4-6 hours.
- Use a 30-degree lateral tilt instead of a 90-degree side-lying position, which loads the trochanter. See the positioning cheat sheet for other positions.
- Float the heels. Support the calves lengthwise on a pillow or use a heel offloading device, with the knees slightly flexed. Do not prop the heels on a rolled towel.
- Keep the head of the bed at 30 degrees or lower unless a higher angle is needed, such as for aspiration risk during tube feeding. Higher angles make the client slide, adding shear over the sacrum.
- Lift, do not drag. Use a lift sheet, a mechanical aid or enough staff.
- Manage moisture. Cleanse promptly after incontinence with a pH-balanced cleanser and apply a barrier product.
- Support nutrition. Screen for malnutrition and involve the dietitian. For adults with a pressure injury, the 2026 guideline cites about 1.2-1.6 g/kg/day of protein, with kidney function checked first.
- Use the right surface: at minimum a pressure-redistribution foam mattress and a pressure-redistributing chair cushion.
Common wrong answers: massaging or vigorously rubbing reddened skin over bony prominences (it can damage injured tissue), ring or donut cushions (their edges create high pressure and impair circulation), and positioning the client on a reddened area.
Turning, skin care and reporting redness can be delegated to assistive personnel; the RN keeps assessment, staging and care planning, as the delegation and prioritization rules explain. For more practice, try the fundamentals and safety practice questions.
What should the nurse document?
- Anatomic location and stage (or unstageable, DTPI, or mucosal and not staged)
- Length, width and depth in centimeters, measured the same way each time
- Wound bed tissue (granulation, slough, eschar), edges, undermining and tunneling
- Exudate, odor, periwound skin and signs of infection
- Pain, whether the injury was present on admission, and the prevention plan
Inspect the wound at each dressing change and fully reassess it at least weekly. If it worsens, document the findings and notify the provider. The wound care and ostomy practice questions build on these skills.
Sample NCLEX pressure injury questions
Sample question 1
The nurse assesses the sacrum of a client who returned from a 6-hour surgical procedure. Which finding should the nurse document as a deep tissue pressure injury?
- Intact skin with a red area that does not blanch
- A pink, moist, shallow wound with exposed dermis
- Intact skin with a maroon area that does not blanch
- An open wound with its base covered by yellow slough
Show answer & rationale
Correct answer: C. Persistent non-blanchable maroon, purple or deep red discoloration is a deep tissue pressure injury, and long surgical immobility is a classic cause. The nurse offloads the area and reassesses it often, because it can open quickly. Option A is a stage 1 injury, whose definition excludes purple or maroon. Option B is a stage 2 injury, partial-thickness loss with exposed dermis. Option D is unstageable, because slough hides the wound base.
Sample question 2
The nurse observes an assistive personnel (AP) caring for a client whose Braden Scale score is 11. Which action by the AP requires the nurse to intervene?
- Placing a pillow lengthwise under the client’s calves to float the heels
- Moving the client up in bed with a lift sheet and a second staff member
- Applying a barrier cream after cleansing the client’s perineal skin
- Rubbing lotion firmly into the reddened skin over the client’s coccyx
Show answer & rationale
Correct answer: D. A score of 11 means high risk, and rubbing reddened skin over a bony prominence can damage tissue that is already injured. The nurse stops the AP and positions the client off the area. Option A is correct heel offloading, with the calves carrying the weight. Option B reduces friction and shear during the move. Option C protects the skin from moisture after incontinence care.
Sample question 3
A client with peripheral arterial disease has a heel wound covered with dry, black, firmly attached eschar. The surrounding skin shows no redness, drainage or fluctuance. Which action should the nurse take?
- Keep the eschar intact and float the heel
- Apply a moist dressing to soften the eschar
- Document the wound as a stage 4 injury
- Scrub the eschar gently during wound cleansing
Show answer & rationale
Correct answer: A. Stable eschar on the heel or an ischemic limb acts as a natural cover and is left in place; the nurse offloads the heel and watches for redness, drainage or fluctuance that would suggest infection. Option B removes that protective cover over poorly perfused tissue. Option C is wrong because the base cannot be seen, so the wound is unstageable. Option D disrupts the eschar and traumatizes the wound.
Sample question 4 (Select all that apply)
The nurse is planning care for a client on bed rest who has a Braden Scale score of 12 and no restrictions on bed position. Which interventions should the nurse include? Select all that apply.
- Place a donut-shaped cushion under the client’s sacrum
- Reposition the client using a 30-degree lateral tilt
- Keep the head of the bed at or below 30 degrees
- Massage the bony prominences with lotion after the bath
- Rest the calves on a pillow so the heels float
- Extend the overnight turning interval to every 6 hours
Show answer & rationale
Correct answers: B, C, E. A 30-degree tilt offloads the sacrum and trochanter (B), a low head of bed limits sliding and shear (C), and supporting the calves lets the heels float (E). Option A concentrates pressure along the cushion’s edges and impairs circulation. Option D can damage tissue over bony prominences. Option F is unsafe for a high-risk client: the classic answer is at least every 2 hours, and current guidance advises against routinely extending turning to 4-6 hours.
Frequently Asked Questions
What are the stages of a pressure injury?
The NPIAP system has four numbered stages plus two categories. Stage 1 is non-blanchable redness of intact skin, stage 2 is partial-thickness loss with exposed dermis, stage 3 is full-thickness loss with visible fat, and stage 4 has exposed or palpable fascia, muscle, tendon, ligament, cartilage or bone. Unstageable injuries have a base hidden by slough or eschar, and deep tissue pressure injuries show persistent maroon or purple discoloration.
How is a stage 1 pressure injury different from a deep tissue pressure injury?
Neither blanches. Stage 1 is redness of intact skin, and its definition excludes purple or maroon. A deep tissue pressure injury is deep red, maroon or purple, or a blood-filled blister, and reflects damage at the bone-muscle interface that can open quickly into a full-thickness wound.
Is a blister a stage 2 pressure injury?
A serum-filled blister caused by pressure is stage 2, whether intact or ruptured. A blood-filled blister is a deep tissue pressure injury. Blisters from burns or medical adhesives are separate wound types and are not staged as pressure injuries.
Can a stage 4 pressure injury become a stage 3 as it heals?
No. Reverse staging is not used. Granulation tissue does not replace lost muscle, fat or bone, so a shrinking stage 4 injury is documented as a healing stage 4 until it closes.
What Braden Scale score indicates high risk?
Braden totals range from 6 to 23, and lower scores mean higher risk. As commonly taught, 15 to 18 is at risk, 13 to 14 is moderate risk, 10 to 12 is high risk, and 9 or less is very high risk. Facilities may set a different at-risk cut-off.
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- NPIAP Pressure Injury Stages (2016 staging system definitions) — Definitions of stages 1-4, unstageable, DTPI, device-related and mucosal membrane pressure injuries
- NPIAP/EPUAP/PPPIA Quick Reference Guide, International Guideline 4th edition (September 2026) — 2-3 hour repositioning, 30-degree tilt, head of bed 30 degrees or lower, heel elevation, weekly reassessment
- International Guideline 2026: Classification chapter — No reverse staging (report 'healing stage 4'); why mucosal injuries are not staged; scar has ~80% strength
- International Guideline 2026: Nutrition chapter — Protein about 1.2-1.6 g/kg/day for adults with a pressure injury, with renal function assessed
- Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019 edition — Avoid massage and vigorous rubbing; no ring or donut devices; pH-balanced cleansers; 30-degree side-lying
- CMS MDS 3.0 RAI Manual v1.20.11, Section M (October 2026) — Do not reverse or back stage; mucosal pressure ulcers are not staged with the skin staging system
- AHRQ Preventing Pressure Ulcers in Hospitals Toolkit: Best Practices — Braden: six subscales, totals 6-23, 18 or less generally at risk; threshold may be adjusted locally
- Hartford Institute for Geriatric Nursing, Try This: Predicting Pressure Injury Risk — Braden tiers: 15-18 at risk, 13-14 moderate, 10-12 high, 9 or less very high; plan from low subscales
Sources checked September 2026.