HESI FUNDAMENTALS PROCTORED EXAM Latest Version 2023 2024
QUESTIONS AND CORRECT ANSWERS WITH RATIONALE
1. The nurse is admitting an older patient from a nursing home. During the
assessment, the nurse 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. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness
skin loss involving epidermis and dermis. The ulcer presents clinically as an
abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable
redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous
fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV
involves full-thickness tissue loss with exposed bone, tendon, or muscle.
2. The nurse is completing a skin assessment on a patient with darkly
pigmented skin. Which item should the nurse use first to assist in staging an
ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is
essential to accurately complete the first step in assessment—inspection—and
,the entire assessment process. Natural light or a halogen light is recommended.
Fluorescent light sources can produce blue tones on darkly pigmented skin and
can interfere with an accurate assessment. Other items that could possibly be
used during the assessment include gloves for
, infection control, a disposable measuring device to measure the size of
the wound, and a cotton-tipped applicator to measure the depth of the
wound, but these items are not the first items used.
3. The nurse is caring for a patient with a Stage IV pressure ulcer.
Which type of healing will the nurse consider when planning care for
this patient?
a. Partial-thickness wound repair
b. Full-thickness wound repair
c. Primary intention
d. Tertiary intention
ANS: B
Stage IV pressure ulcers are full-thickness wounds that extend into the dermis
and heal by scar formation because the deeper structures do not regenerate,
hence the need for full-thickness repair. The full-thickness repair has four
phases: hemostasis, inflammatory, proliferative, and maturation. A wound
heals by primary intention when wounds such as surgical wounds have little
tissue loss; the skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repairs are done on partial-thickness wounds
that are shallow, involving loss of the epidermis and maybe partial loss of the
dermis. These wounds heal by regeneration because the epidermis
regenerates. Tertiary intention is seen when a wound is left open for several
days, and then the wound edges are approximated. Wound closure is delayed
until risk of infection is resolved.
4. The nurse is caring for a group of patients. Which patient will the nurse
see first?
a. A patient with a Stage IV pressure ulcer
b. A patient with a Braden Scale score of 18
QUESTIONS AND CORRECT ANSWERS WITH RATIONALE
1. The nurse is admitting an older patient from a nursing home. During the
assessment, the nurse 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. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness
skin loss involving epidermis and dermis. The ulcer presents clinically as an
abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable
redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous
fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV
involves full-thickness tissue loss with exposed bone, tendon, or muscle.
2. The nurse is completing a skin assessment on a patient with darkly
pigmented skin. Which item should the nurse use first to assist in staging an
ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is
essential to accurately complete the first step in assessment—inspection—and
,the entire assessment process. Natural light or a halogen light is recommended.
Fluorescent light sources can produce blue tones on darkly pigmented skin and
can interfere with an accurate assessment. Other items that could possibly be
used during the assessment include gloves for
, infection control, a disposable measuring device to measure the size of
the wound, and a cotton-tipped applicator to measure the depth of the
wound, but these items are not the first items used.
3. The nurse is caring for a patient with a Stage IV pressure ulcer.
Which type of healing will the nurse consider when planning care for
this patient?
a. Partial-thickness wound repair
b. Full-thickness wound repair
c. Primary intention
d. Tertiary intention
ANS: B
Stage IV pressure ulcers are full-thickness wounds that extend into the dermis
and heal by scar formation because the deeper structures do not regenerate,
hence the need for full-thickness repair. The full-thickness repair has four
phases: hemostasis, inflammatory, proliferative, and maturation. A wound
heals by primary intention when wounds such as surgical wounds have little
tissue loss; the skin edges are approximated or closed, and the risk for
infection is low. Partial-thickness repairs are done on partial-thickness wounds
that are shallow, involving loss of the epidermis and maybe partial loss of the
dermis. These wounds heal by regeneration because the epidermis
regenerates. Tertiary intention is seen when a wound is left open for several
days, and then the wound edges are approximated. Wound closure is delayed
until risk of infection is resolved.
4. The nurse is caring for a group of patients. Which patient will the nurse
see first?
a. A patient with a Stage IV pressure ulcer
b. A patient with a Braden Scale score of 18
