SKIN Integrity HESI Study Guide Practice Test.
In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - CORRECT ANSWER Apply light pressure to the area with the fingertips.
Measure the diameter of the redness.
The sacral area ...
SKIN Integrity HESI Study Guide Practice Test.
In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? - CORRECT ANSWER 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? - CORRECT ANSWER Reactive hyperemia.
Which areas are most important for the nurse to observe for additional pressure ulcers? - CORRECT ANSWER Heels and ankles.
What action should the nurse implement? - CORRECT ANSWER Identify these areas as sites where pressure damage has occurred.
Which etiology identified by the nurse is accurate? - CORRECT ANSWER Impaired physical mobility.
Which goal will the nurse include in Alexander's plan of care? - CORRECT ANSWER Client's skin will remain intact.
To provide pressure relief at night, the nurse teaches Alexander to sleep in which position? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER Transparent film dressing.
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