PN HESI SKIN INTEGRITY (With complete solution)

The PN measures the length of time that the redness lasts. Which additional wound assessment technique is indicated? correct answers Apply light pressure to the area with the fingertips. How should the PN document this finding? correct answers Reactive hyperemia. Which areas are most important for the PN to observe for additional pressure ulcers? correct answers Heels and ankles What action should the PN implement? correct answers Identify these areas as sites where pressure damage has occurred. What etiology should the PN identify? correct answers Impaired motor function. Which goal will the PN include in Trey's plan of care? correct answers Client's skin will remain intact. To provide pressure relief at night, the PN reminds Trey to sleep in which position? correct answers Thirty-degree lateral inclined position. Upon learning that Trey has a pressure-reducing gel chair cushion for his wheelchair, which action should the PN take? correct answers Encourage him to continue to use this device in his wheelchair at all times. The PN shows Trey how to apply a transparent film dressing over the sacral area and advises him to follow which schedule for dressing changes? correct answers Once weekly. Which documentation best describes the drainage from Trey's wound? correct answers Purulent. Which intervention is important to reduce the effect of the diarrhea on Trey's skin? correct answers Apply a moisture-repellent ointment to intact skin areas. What action should the PN take? correct answers Assure the second nurse that written instructions in the client's room are effective and do not violate any client rights. Which protective equipment should the PN use when providing the prescribed wound care? correct answers Gloves, gown, goggles, and face mask. What equipment will the PN use to assess the length of the tract? correct answers Sterile cotton-tipped applicator. Which irrigation technique is best? correct answers Apply steady pressure using a 35-mL syringe and 19 gauge tip. How many mL of medication will the PN administer? correct answers 30