EVOLVE PHARMACOLOGY HESI
EXAM 2025 LATEST NEWEST
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The nurse identifies that the client has developed a Stage 1 pressure injury and is concerned
that the client may have other pressure injuries. Which areas are most important for the nurse
to observe for additional pressure injuries (PI)?
,A) Distal tips of the toes: Ulcers occur on the tips of the toes when there is diminished arterial
circulation. That is not the client's primary problem.
B) Lower abdominal folds: this is not an area where PI typically occur. More typical skin
breakdown here is escoriation.
C) Ischial tuberosities: PI typically occur over bony prominences, such as the heels, ankles,
ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial
tuberosities at greater risk for breakdown. While bony prominences are the most common
sites for PI development, the nurse should perform a complete skin assessment.
D) Thighs and calves: These are areas (pressure points) where PI typically do not occur.
C) Ischial tuberosities: PI typically occur over bony prominences, such as the heels, ankles,
ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial
tuberosities at greater risk for breakdown. While bony prominences are the most common
sites for PI development, the nurse should perform 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 (HCP) that the client is retaining excess 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.
D) Identify these areas as sites where pressure damage has occurred.
Palpable changes in the consistency of the tissue underlying a bony prominence, often
described as "spongy," is an indication that pressure damage has occurred. Additional
manifestations may include a change in skin temperature and induration.
The PN and RN team leader identify a priority problem for the client's plan of care as
"impaired skin integrity." Which etiology: "medicine" identified by the nurse is accurate?
, A) Noncompliance with turning schedule.
B) Poor nutritional intake.
C) Impaired physical mobility.
D) Impaired adjustment.
C) Impaired physical mobility
Since the client is "paraplegic":(the inability to voluntarily move the lower parts of the body),
they have impaired physical mobility, a major factor that contributes to PI development.
After establishing the priority diagnosis, the nurse identifies goals and expected outcomes.
Which goal should the nurses include in the client's plan of care?
A) The client's skin will remain intact without deterioration.
B) The client's motor function will be restored.
C) Client teaching will be provided.
D) Impaired skin integrity will not occur.
A) The client's skin will remain intact without deterioration.
A goal should be a broad statement that includes, in positive terminology, the intended effect
of the planned interventions.
At the end of the appointment, the nurse provides client teaching about measures to promote
healing and to prevent further tissue destruction. To provide pressure relief at night, the nurse
teaches the client to sleep in which position?
A) Supine with the head of the bed elevated.
B) Supine with a foam wedge between the knees.
C) Thirty-degree lateral inclined position.
D) Full side-lying position supported with pillows.
C) Thirty-degree lateral inclined position.
EXAM 2025 LATEST NEWEST
UPDATE WITH ACTUAL
QUESTIONS AND DETAILED
VERIFIED ANSWERS WITH
RATIONALES (100% CORRECT)
//BRAND NEW!! /ALREADY
GRADED A+ WITH
GUARANTEED SUCCESS AFTER
DOWNLOAD (ALL YOU NEED TO
PASS YOUR EXAMS
The nurse identifies that the client has developed a Stage 1 pressure injury and is concerned
that the client may have other pressure injuries. Which areas are most important for the nurse
to observe for additional pressure injuries (PI)?
,A) Distal tips of the toes: Ulcers occur on the tips of the toes when there is diminished arterial
circulation. That is not the client's primary problem.
B) Lower abdominal folds: this is not an area where PI typically occur. More typical skin
breakdown here is escoriation.
C) Ischial tuberosities: PI typically occur over bony prominences, such as the heels, ankles,
ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial
tuberosities at greater risk for breakdown. While bony prominences are the most common
sites for PI development, the nurse should perform a complete skin assessment.
D) Thighs and calves: These are areas (pressure points) where PI typically do not occur.
C) Ischial tuberosities: PI typically occur over bony prominences, such as the heels, ankles,
ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial
tuberosities at greater risk for breakdown. While bony prominences are the most common
sites for PI development, the nurse should perform 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 (HCP) that the client is retaining excess 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.
D) Identify these areas as sites where pressure damage has occurred.
Palpable changes in the consistency of the tissue underlying a bony prominence, often
described as "spongy," is an indication that pressure damage has occurred. Additional
manifestations may include a change in skin temperature and induration.
The PN and RN team leader identify a priority problem for the client's plan of care as
"impaired skin integrity." Which etiology: "medicine" identified by the nurse is accurate?
, A) Noncompliance with turning schedule.
B) Poor nutritional intake.
C) Impaired physical mobility.
D) Impaired adjustment.
C) Impaired physical mobility
Since the client is "paraplegic":(the inability to voluntarily move the lower parts of the body),
they have impaired physical mobility, a major factor that contributes to PI development.
After establishing the priority diagnosis, the nurse identifies goals and expected outcomes.
Which goal should the nurses include in the client's plan of care?
A) The client's skin will remain intact without deterioration.
B) The client's motor function will be restored.
C) Client teaching will be provided.
D) Impaired skin integrity will not occur.
A) The client's skin will remain intact without deterioration.
A goal should be a broad statement that includes, in positive terminology, the intended effect
of the planned interventions.
At the end of the appointment, the nurse provides client teaching about measures to promote
healing and to prevent further tissue destruction. To provide pressure relief at night, the nurse
teaches the client to sleep in which position?
A) Supine with the head of the bed elevated.
B) Supine with a foam wedge between the knees.
C) Thirty-degree lateral inclined position.
D) Full side-lying position supported with pillows.
C) Thirty-degree lateral inclined position.
