HESI PN LEADERSHIP PROCTORED EXAM ( 11 VERSIONS) (LATEST-2021): (ANSWERS VERIFIED 100% CORRECT)

HESI LEADERSHIP PROCTORED EXAM 1. 1. The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question? a. Use a low-air-loss therapy unit. b. Irrigate with Dakin’s solution. c. Apply a hydrogel dressing. d. Consult a dietitian. ANS: B Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin’s solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate. 2. The nurse is completing an assessment of the patient’s skin’s integrity. Which assessment is the priority? a. Pressure points b. Breath sounds c. Bowel sounds d. Pulse points ANS: A Observe pressure points such as bony prominences. The nurse continually assesses the skin for signs of ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. Assessment of pulses, breath sounds, and bowel sounds is part of a head-totoe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part or priority of a skin assessment. 3. The nurse is completing a skin risk assessment using the Braden Scale. 1 The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient?