SKIN Integrity HESI Study Guide Practice Test.
In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - CORRECT ANSWER Apply light pressure to the area with the fingertips. Measure the diameter of the redness.
The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? - CORRECT ANSWER Reactive hyperemia.
Which areas are most important for the nurse to observe for additional pressure ulcers? - CORRECT ANSWER Heels and ankles.
What action should the nurse implement? - CORRECT ANSWER Identify these areas as sites where pressure damage has occurred.
Which etiology identified by the nurse is accurate? - CORRECT ANSWER Impaired physical mobility.
Which goal will the nurse include in Alexander's plan of care? - CORRECT ANSWER Client's skin will remain intact.
To provide pressure relief at night, the nurse teaches Alexander to sleep in which position? - CORRECT ANSWER Thirty-degree lateral inclined position.
Upon learning that Alexander has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take? - CORRECT ANSWER Encourage him to continue to use this device in his wheelchair at all times.
The nurse teaches Alexander to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer? - CORRECT ANSWER Transparent film dressing.
In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - CORRECT ANSWER Apply light pressure to the area with the fingertips. Measure the diameter of the redness.
The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? - CORRECT ANSWER Reactive hyperemia.
Which areas are most important for the nurse to observe for additional pressure ulcers? - CORRECT ANSWER Heels and ankles.
What action should the nurse implement? - CORRECT ANSWER Identify these areas as sites where pressure damage has occurred.
Which etiology identified by the nurse is accurate? - CORRECT ANSWER Impaired physical mobility.
Which goal will the nurse include in Alexander's plan of care? - CORRECT ANSWER Client's skin will remain intact.
To provide pressure relief at night, the nurse teaches Alexander to sleep in which position? - CORRECT ANSWER Thirty-degree lateral inclined position.
Upon learning that Alexander has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take? - CORRECT ANSWER Encourage him to continue to use this device in his wheelchair at all times.
The nurse teaches Alexander to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer? - CORRECT ANSWER Transparent film dressing.
