Skin integrity HESI Test Questions and Answers Graded A
In addition to measuring the length of time the
redness lasts, which assessment measure(s)
should the nurse perform? - ANSWER - The nurse teaches Alexander to apply a dressing
Apply light pressure to the area with the over the sacral area. Which type of dressing is
fingertips. most likely to be used over the stage 1 pressure
Measure the diameter of the redness. ulcer? - ANSWER -Transparent film
dressing.
The sacral area has remained red for 2 hours
and does not blanch when tested. Which is the Which documentation best describes the
best description for the nurse to document? - drainage from Alexander's wound? -
ANSWER -Reactive hyperemia. ANSWER -Purulent
Which areas are most important for the nurse to Which intervention is important to reduce the
observe for additional pressure ulcers? - effect of the diarrhea on Alexander's skin? -
ANSWER -Heels and ankles. ANSWER -Apply a moisture-repellent
ointment to intact skin areas.
What action should the nurse implement? -
ANSWER -Identify these areas as sites What action should the nurse take? -
where pressure damage has occurred. ANSWER -Assure the charge nurse that
written instructions in the client's room are
effective and do not violate any client rights.
Which etiology identified by the nurse is
accurate? - ANSWER -Impaired physical
mobility. After reviewing the results of the wound culture,
which type of precautions should the nurse and
staff use when caring for this client? -
Which goal will the nurse include in Alexander's ANSWER -Contact precautions.
plan of care? - ANSWER -Client's skin will
remain intact.
Which equipment will the nurse use to assess the
length of the tract? - ANSWER -Sterile
To provide pressure relief at night, the nurse cotton-tipped applicator.
teaches Alexander to sleep in which position? -
ANSWER -Thirty-degree lateral inclined
position. Which irrigation technique is best? -
ANSWER -Apply steady pressure using a
35 mL syringe and 19 gauge needle.
Upon learning that Alexander has a pressure-
reducing gel chair cushion for his wheelchair,
which action should the nurse take? - What is the purpose of this type of dressing? -
ANSWER -Encourage him to continue to ANSWER -Mechanically debride the tissue.
use this device in his wheelchair at all times.
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In addition to measuring the length of time the
redness lasts, which assessment measure(s)
should the nurse perform? - ANSWER - The nurse teaches Alexander to apply a dressing
Apply light pressure to the area with the over the sacral area. Which type of dressing is
fingertips. most likely to be used over the stage 1 pressure
Measure the diameter of the redness. ulcer? - ANSWER -Transparent film
dressing.
The sacral area has remained red for 2 hours
and does not blanch when tested. Which is the Which documentation best describes the
best description for the nurse to document? - drainage from Alexander's wound? -
ANSWER -Reactive hyperemia. ANSWER -Purulent
Which areas are most important for the nurse to Which intervention is important to reduce the
observe for additional pressure ulcers? - effect of the diarrhea on Alexander's skin? -
ANSWER -Heels and ankles. ANSWER -Apply a moisture-repellent
ointment to intact skin areas.
What action should the nurse implement? -
ANSWER -Identify these areas as sites What action should the nurse take? -
where pressure damage has occurred. ANSWER -Assure the charge nurse that
written instructions in the client's room are
effective and do not violate any client rights.
Which etiology identified by the nurse is
accurate? - ANSWER -Impaired physical
mobility. After reviewing the results of the wound culture,
which type of precautions should the nurse and
staff use when caring for this client? -
Which goal will the nurse include in Alexander's ANSWER -Contact precautions.
plan of care? - ANSWER -Client's skin will
remain intact.
Which equipment will the nurse use to assess the
length of the tract? - ANSWER -Sterile
To provide pressure relief at night, the nurse cotton-tipped applicator.
teaches Alexander to sleep in which position? -
ANSWER -Thirty-degree lateral inclined
position. Which irrigation technique is best? -
ANSWER -Apply steady pressure using a
35 mL syringe and 19 gauge needle.
Upon learning that Alexander has a pressure-
reducing gel chair cushion for his wheelchair,
which action should the nurse take? - What is the purpose of this type of dressing? -
ANSWER -Encourage him to continue to ANSWER -Mechanically debride the tissue.
use this device in his wheelchair at all times.
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