Which action by the nurse is appropriate when evaluating a patient with a deep wound covered with a yellowish tan tissue on the right lower leg?
O Contact the health care provider as the wound cannot be staged at this time
O Determine that it is a Stage 3 pressure injury that should be cleansed with soap and water
O Identify the wound as a deep tissue pressure injury and elevate the leg on a pillow
O Document as a Stage 1 pressure injury and cover with transparent film dressing