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HESI: Skin Integrity Questions with Correct
Answers | Updated (100% Correct Answers)
The nurse observes that the reddish area round, 3 cm diameter, and
is directly over the client's sacrum. The skin is intact. In addition to
measuring the length of the time the redness lasts, which
assessment measure should the nurse perform? (select all that
apply).
A) Apply light pressure to the area with the fingertips.
B) Measure the diameter of the redness.
B) Observe for wound approximation.
C) Obtain a wound culture
D) Gently lift a fold of skin. Answer: A) Apply light pressure to the
area with the fingertips.
Rationale: The RN applies light pressure with the fingertips to asses
for blanching. This is a normal response in light-skinned clients,
which indicates there is no tissue perfusion impairment.
B)Measure the diameter of the redness.
Rationale: the area of redness should be measured to evaluate
progression or healing.
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The sacral area has remained red for two hours and does not blanch
when tested. How will the nurse document this finding?
A) Excessive pallor
B) Unusual skin mottling
C) Dependent sacral rubor
D) Reactive hyperemia Answer: D) Reactive hyperemia
Rationale: reactive hyperemia occurs when tissue is relieved of
pressure. Is is considered abnormal when the redness lasts longer
than 1 hour and the surrounding tissue does not blanch.
The nurse identifies that Aaron has developed a Stage I pressure
ulcer. The nurse is concerned that Aaron may have other pressure
ulcers. Which areas are most important for the nurse to observe for
additional pressure ulcers?
A) Distal tips of the toes.
B) Lower abdominal folds
C) Heels and ankles
D) Thighs and calves Answer: C) Heels and ankles
Rationale: pressure ulcers typically occur over bony prominences,
such as the heels, and sacral area. While bony prominences are the
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, 3
most common sites for pressure ulcer development. the RN should
perfom a complete skin assessment.
During the assessment of these high-risk areas, the nurse finds no
redness, but the underlying tissue feels spongy. What action should
the nurse implement?
A) Apply heat to reduce the inflammation that has occurred at these
sites?
B) Notify the healthcare provider that the client is retaining
excessive fluid
C) Reassure the client that no pressure damage is present at these
sites.
D) Identify these areas as sites where pressure damage has
occurred. Answer: D) Identify these areas as sites where pressure
damage has occurred.
Rationale: Palpable changes in the consistency of the tissue
underlying a bony prominence, often described as :spongy" or
"beefy," are an indication that pressure damage has occurred.
Additional manifestations may include a change in skin temperature
and induration.
The nurse identifies a priority problem for Aaron's plan of care as
"Impaired skin integrity". What etiology should the nurse identify?
© 2025 All rights reserved
HESI: Skin Integrity Questions with Correct
Answers | Updated (100% Correct Answers)
The nurse observes that the reddish area round, 3 cm diameter, and
is directly over the client's sacrum. The skin is intact. In addition to
measuring the length of the time the redness lasts, which
assessment measure should the nurse perform? (select all that
apply).
A) Apply light pressure to the area with the fingertips.
B) Measure the diameter of the redness.
B) Observe for wound approximation.
C) Obtain a wound culture
D) Gently lift a fold of skin. Answer: A) Apply light pressure to the
area with the fingertips.
Rationale: The RN applies light pressure with the fingertips to asses
for blanching. This is a normal response in light-skinned clients,
which indicates there is no tissue perfusion impairment.
B)Measure the diameter of the redness.
Rationale: the area of redness should be measured to evaluate
progression or healing.
© 2025 All rights reserved
,2
The sacral area has remained red for two hours and does not blanch
when tested. How will the nurse document this finding?
A) Excessive pallor
B) Unusual skin mottling
C) Dependent sacral rubor
D) Reactive hyperemia Answer: D) Reactive hyperemia
Rationale: reactive hyperemia occurs when tissue is relieved of
pressure. Is is considered abnormal when the redness lasts longer
than 1 hour and the surrounding tissue does not blanch.
The nurse identifies that Aaron has developed a Stage I pressure
ulcer. The nurse is concerned that Aaron may have other pressure
ulcers. Which areas are most important for the nurse to observe for
additional pressure ulcers?
A) Distal tips of the toes.
B) Lower abdominal folds
C) Heels and ankles
D) Thighs and calves Answer: C) Heels and ankles
Rationale: pressure ulcers typically occur over bony prominences,
such as the heels, and sacral area. While bony prominences are the
© 2025 All rights reserved
, 3
most common sites for pressure ulcer development. the RN should
perfom a complete skin assessment.
During the assessment of these high-risk areas, the nurse finds no
redness, but the underlying tissue feels spongy. What action should
the nurse implement?
A) Apply heat to reduce the inflammation that has occurred at these
sites?
B) Notify the healthcare provider that the client is retaining
excessive fluid
C) Reassure the client that no pressure damage is present at these
sites.
D) Identify these areas as sites where pressure damage has
occurred. Answer: D) Identify these areas as sites where pressure
damage has occurred.
Rationale: Palpable changes in the consistency of the tissue
underlying a bony prominence, often described as :spongy" or
"beefy," are an indication that pressure damage has occurred.
Additional manifestations may include a change in skin temperature
and induration.
The nurse identifies a priority problem for Aaron's plan of care as
"Impaired skin integrity". What etiology should the nurse identify?
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