A nurse notices redness over a patient's sacrum that does not turn white when pressed. What does this indicate?

A category 1 pressure ulcer needing immediate action

Normal skin that needs no attention

A bruise that will fade on its own

Which combination best captures the main pressure ulcer risk factors?

Immobility, poor nutrition, moisture, friction and reduced sensation

Good mobility and a healthy diet

Young age and frequent movement

An immobile patient is assessed as high risk using the Waterlow score. What should follow?

A prevention plan including repositioning, a suitable surface and skin checks

No action, as the score is just a number

Waiting for skin damage before acting

Daily weighing instead of prevention

Why is inspecting the skin of a patient with darker skin tone especially important?

Early pressure damage may look purple or different in tone, not red

Darker skin cannot develop pressure ulcers

Pressure ulcers only affect lighter skin

Skin colour has no bearing on assessment

Part B3 of 8 Assessing Needs and Planning Care Chapter 39 of 75

Pressure Ulcer Risk (Waterlow/Braden) Questions

NMC CBT pressure ulcer practice: risk factors, Waterlow and Braden tools, the SSKIN bundle, repositioning, and worked scenario answers.

Start reading ← Back to the bank ~5 min read

By JobLabs Editorial · UK healthcare reference editorial team

· July 16, 2026 · Updated Jul 17, 2026 · 2 min read

Pressure ulcers are largely preventable, which is exactly why they matter so much: when one develops, it usually means prevention broke down somewhere. The CBT tests whether you can spot who is at risk, prevent damage, and recognise the earliest sign before it worsens.

Why they happen

Pressure ulcers form where pressure on the skin is not relieved and the tissue is vulnerable. The main risk factors cluster together: immobility, poor nutrition, moisture from incontinence or sweat, friction and shear as a patient slides or is dragged, and reduced sensation that stops someone feeling the discomfort that would normally make them shift. An immobile, poorly nourished patient who cannot reposition themselves is at high risk.

Scoring the risk

Tools like Waterlow and Braden turn these factors into a score that flags who needs prevention. As with every screening tool in this section, the score is only useful if it drives action. A high Waterlow score should lead to a prevention plan, not sit in the notes while everyone waits for skin damage to appear.

Preventing damage: SSKIN

The prevention framework to know is SSKIN: Surface, the right mattress or cushion; Skin inspection; Keep moving, meaning regular repositioning; Incontinence and moisture care; and Nutrition and hydration. Repositioning is central, commonly around every two to four hours for an at-risk patient, and more often if the skin is already showing early change.

The earliest sign

The single most important thing to recognise is non-blanching redness: redness over a bony area that does not turn white when pressed. That is a category 1 pressure ulcer and a signal to act at once, relieve the pressure, review the plan, document it. On darker skin, early damage may not look red at all; it may show as a change in tone, warmth or firmness. Only looking for redness means missing pressure damage on darker skin, which is why informed inspection matters. Next: mental health and self-harm risk. Five pressure ulcer scenarios first.

Sources & further reading

Key takeaway from Pressure Ulcer Risk (Waterlow/Braden) Questions

Frequently asked questions

What is the earliest sign of a pressure ulcer?

Redness that does not turn white when pressed, called non-blanching erythema, over a bony area. On darker skin it may look purple or different in tone rather than red. It is a category 1 pressure ulcer and a signal to act immediately.

What is the SSKIN bundle?

A prevention checklist: Surface (the right mattress or cushion), Skin inspection, Keep moving (repositioning), Incontinence and moisture care, and Nutrition and hydration. Used together, these reduce the chance of a pressure ulcer developing.

How often should an at-risk patient be repositioned?

At intervals based on their individual risk and skin condition, commonly around every two to four hours, and more often if the skin shows early damage. Repositioning relieves pressure on vulnerable areas, and the plan is reviewed as their risk changes.

Check your understanding

Quick quiz: Pressure Ulcer Risk (Waterlow/Braden) Questions

5questions. Click an answer to see the explanation. Your score is saved on this device only.

1
A nurse notices redness over a patient's sacrum that does not turn white when pressed. What does this indicate?
Non-blanching redness over a bony area is the earliest sign of pressure damage, a category 1 pressure ulcer. It calls for immediate action: relieve pressure, review the prevention plan, and document it. Treating it as normal skin lets the damage progress.
2
Which combination best captures the main pressure ulcer risk factors?
Pressure ulcers develop where pressure is unrelieved and the skin is vulnerable: immobility, poor nutrition, moisture, friction and shear, and reduced sensation all contribute. The other options describe protective factors, not risks.
3
What does the K in the SSKIN bundle stand for?
SSKIN stands for Surface, Skin inspection, Keep moving, Incontinence and moisture, and Nutrition. Keep moving, regular repositioning to relieve pressure, is central to prevention. The other options are unrelated to the bundle.
4
An immobile patient is assessed as high risk using the Waterlow score. What should follow?
A risk score exists to drive prevention. A high Waterlow score should lead to a plan: repositioning, an appropriate mattress or cushion, skin inspection, and attention to moisture and nutrition. Waiting for damage before acting defeats the purpose of screening.
5
Why is inspecting the skin of a patient with darker skin tone especially important?
On darker skin, early pressure damage may not appear as redness and can be missed if you only look for red. It may show as a change in tone, warmth, or firmness. Careful, informed inspection prevents early damage being overlooked.