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
HESI FUNDAMENTALS PROCTORED EXAM Latest Version 2023 2024 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE
, 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
HESI FUNDAMENTALS PROCTORED EXAM Latest Version 2023 2024 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE
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
HESI FUNDAMENTALS PROCTORED EXAM Latest Version 2023 2024 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE
, 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
HESI FUNDAMENTALS PROCTORED EXAM Latest Version 2023 2024 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALE
