1
HESI: Skin Integrity Questions and
Answers (100% Correct Answers)
Already Graded A+
The nurse observes that the reddish area round, 3 cm
diameter, and is directly over the client's sacrum. The skin is
© 2026 Assignment
intact. In addition to measuring the length of the time the
redness lasts, which assessment measure should the nurse
perform? (select all that apply).
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Expert
A) Apply light pressure to the area with the fingertips.
B) Measure the diameter of the redness.
B) Observe for wound approximation.
C) Obtain a wound culture
D) Gently lift a fold of skin. Ans: A) Apply light pressure to
the area with the fingertips.
Rationale: The RN applies light pressure with the fingertips to
asses for blanching. This is a normal response in light-skinned
clients, which indicates there is no tissue perfusion
impairment.
B)Measure the diameter of the redness.
Rationale: the area of redness should be measured to evaluate
progression or healing.
, 2
The sacral area has remained red for two hours and does not
blanch when tested. How will the nurse document this finding?
A) Excessive pallor
B) Unusual skin mottling
C) Dependent sacral rubor
D) Reactive hyperemia Ans: D) Reactive hyperemia
© 2026 Assignment
Rationale: reactive hyperemia occurs when tissue is relieved of
Guru01 - Stuvia
pressure. Is is considered abnormal when the redness lasts
Expert
longer than 1 hour and the surrounding tissue does not
blanch.
The nurse identifies that Aaron has developed a Stage I
pressure ulcer. The nurse is concerned that Aaron may have
other pressure ulcers. Which areas are most important for the
nurse to observe for additional pressure ulcers?
A) Distal tips of the toes.
B) Lower abdominal folds
C) Heels and ankles
D) Thighs and calves Ans: C) Heels and ankles
Rationale: pressure ulcers typically occur over bony
prominences, such as the heels, and sacral area. While bony
prominences are the most common sites for pressure ulcer
development. the RN should perfom a complete skin
assessment.
, 3
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 that the client is retaining
excessive fluid
© 2026 Assignment
C) Reassure the client that no pressure damage is present at
these sites.
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D) Identify these areas as sites where pressure damage has
Expert
occurred. Ans: D) Identify these areas as sites where pressure
damage has occurred.
Rationale: Palpable changes in the consistency of the tissue
underlying a bony prominence, often described as :spongy" or
"beefy," are an indication that pressure damage has occurred.
Additional manifestations may include a change in skin
temperature and induration.
The nurse identifies a priority problem for Aaron's plan of care
as "Impaired skin integrity". What etiology should the nurse
identify?
A) Noncompliance with turning schedule
B) Poor nutritional intake
C) Impaired physical mobility
D) Impaired adjustment Ans: C) Impaired physical mobility
HESI: Skin Integrity Questions and
Answers (100% Correct Answers)
Already Graded A+
The nurse observes that the reddish area round, 3 cm
diameter, and is directly over the client's sacrum. The skin is
© 2026 Assignment
intact. In addition to measuring the length of the time the
redness lasts, which assessment measure should the nurse
perform? (select all that apply).
Guru01 - Stuvia
Expert
A) Apply light pressure to the area with the fingertips.
B) Measure the diameter of the redness.
B) Observe for wound approximation.
C) Obtain a wound culture
D) Gently lift a fold of skin. Ans: A) Apply light pressure to
the area with the fingertips.
Rationale: The RN applies light pressure with the fingertips to
asses for blanching. This is a normal response in light-skinned
clients, which indicates there is no tissue perfusion
impairment.
B)Measure the diameter of the redness.
Rationale: the area of redness should be measured to evaluate
progression or healing.
, 2
The sacral area has remained red for two hours and does not
blanch when tested. How will the nurse document this finding?
A) Excessive pallor
B) Unusual skin mottling
C) Dependent sacral rubor
D) Reactive hyperemia Ans: D) Reactive hyperemia
© 2026 Assignment
Rationale: reactive hyperemia occurs when tissue is relieved of
Guru01 - Stuvia
pressure. Is is considered abnormal when the redness lasts
Expert
longer than 1 hour and the surrounding tissue does not
blanch.
The nurse identifies that Aaron has developed a Stage I
pressure ulcer. The nurse is concerned that Aaron may have
other pressure ulcers. Which areas are most important for the
nurse to observe for additional pressure ulcers?
A) Distal tips of the toes.
B) Lower abdominal folds
C) Heels and ankles
D) Thighs and calves Ans: C) Heels and ankles
Rationale: pressure ulcers typically occur over bony
prominences, such as the heels, and sacral area. While bony
prominences are the most common sites for pressure ulcer
development. the RN should perfom a complete skin
assessment.
, 3
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 that the client is retaining
excessive fluid
© 2026 Assignment
C) Reassure the client that no pressure damage is present at
these sites.
Guru01 - Stuvia
D) Identify these areas as sites where pressure damage has
Expert
occurred. Ans: D) Identify these areas as sites where pressure
damage has occurred.
Rationale: Palpable changes in the consistency of the tissue
underlying a bony prominence, often described as :spongy" or
"beefy," are an indication that pressure damage has occurred.
Additional manifestations may include a change in skin
temperature and induration.
The nurse identifies a priority problem for Aaron's plan of care
as "Impaired skin integrity". What etiology should the nurse
identify?
A) Noncompliance with turning schedule
B) Poor nutritional intake
C) Impaired physical mobility
D) Impaired adjustment Ans: C) Impaired physical mobility
