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Skin integrity HESI Questions and Answers
In addition to measuring the length of time the redness lasts,
which assessment measure(s) should the nurse perform?
Ans: 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?
Ans: Reactive hyperemia.
Which areas are most important for the nurse to observe for
additional pressure ulcers?
Ans: Heels and ankles.
What action should the nurse implement?
Ans: Identify these areas as sites where pressure damage has occurred.
Which etiology identified by the nurse is accurate?
Ans: Impaired physical mobility.
Which goal will the nurse include in Alexander's plan of care?
Ans: Client's skin will remain intact.
To provide pressure relief at night, the nurse teaches Alexander to
sleep in which position?
Ans: 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?
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, 2 | Page
Ans: 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?
Ans: Transparent film dressing.
Which documentation best describes the drainage from
Alexander's wound?
Ans: Purulent
Which intervention is important to reduce the effect of the
diarrhea on Alexander's skin?
Ans: Apply a moisture-repellent ointment to intact skin areas.
What action should the nurse take?
Ans: Assure the charge nurse that written instructions in the client's
room are effective and do not violate any client rights.
After reviewing the results of the wound culture, which type of
precautions should the nurse and staff use when caring for this
client?
Ans: Contact precautions.
Which equipment will the nurse use to assess the length of the
tract?
Ans: Sterile cotton-tipped applicator.
Which irrigation technique is best?
Ans: Apply steady pressure using a 35 mL syringe and 19 gauge needle.
What is the purpose of this type of dressing?
© 2025 All rights reserved
Skin integrity HESI Questions and Answers
In addition to measuring the length of time the redness lasts,
which assessment measure(s) should the nurse perform?
Ans: 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?
Ans: Reactive hyperemia.
Which areas are most important for the nurse to observe for
additional pressure ulcers?
Ans: Heels and ankles.
What action should the nurse implement?
Ans: Identify these areas as sites where pressure damage has occurred.
Which etiology identified by the nurse is accurate?
Ans: Impaired physical mobility.
Which goal will the nurse include in Alexander's plan of care?
Ans: Client's skin will remain intact.
To provide pressure relief at night, the nurse teaches Alexander to
sleep in which position?
Ans: 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?
© 2025 All rights reserved
, 2 | Page
Ans: 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?
Ans: Transparent film dressing.
Which documentation best describes the drainage from
Alexander's wound?
Ans: Purulent
Which intervention is important to reduce the effect of the
diarrhea on Alexander's skin?
Ans: Apply a moisture-repellent ointment to intact skin areas.
What action should the nurse take?
Ans: Assure the charge nurse that written instructions in the client's
room are effective and do not violate any client rights.
After reviewing the results of the wound culture, which type of
precautions should the nurse and staff use when caring for this
client?
Ans: Contact precautions.
Which equipment will the nurse use to assess the length of the
tract?
Ans: Sterile cotton-tipped applicator.
Which irrigation technique is best?
Ans: Apply steady pressure using a 35 mL syringe and 19 gauge needle.
What is the purpose of this type of dressing?
© 2025 All rights reserved
