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HESI Skin Integrity Exam Questions With Correct Answers
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HESI Skin Integrity Exam Questions With CorrectAnswers 2024-2025
The reddened area is noted to be round with a 3 cm diameter, positioned directly over
the client's sacrum. The skin remains intact. In addition to the length of time that this
redness remains, which of the following assessment measures should be performed by
the nurse? (Select all that apply.)
A) Using your fingertips lightly press on the area.
B) Measure the diameter of the redness.
B) Observe for wound approximation.
C) Obtain a wound culture
D) Elevate a skin fold lightly. - Answer A) Using the fingertips, lightly press on an area
and observe for blanching. This is the expected response of light-skinned clients. This is
indicative that there is no restriction in the tissue perfusion.
B) Measure the diameter of the redness.
Rationale: the size of the redness should be measured to note improvement or
resolution.
The client's sacral area has been red for two hours and does not blanch upon testing.
How would the nurse record this?
A) Excessive pallor
B) Abnormal skin mottling
C) Dependent sacral rubor
D) Reactive hyperemia - Answer D) Reactive hyperemia
Rationale: reactive hyperemia is the normal hyperemic response of the tissues after
being relieved of pressure. It is considered abnormal when the resultant redness
, persists for more than 1 hour and the tissues surrounding the area do not blanch.
The nurse identifies that Aaron has developed a Stage I pressure ulcer. The nurse
believes that Aaron may have other pressure ulcers as well. Which of the following
areas would be most important for the nurse to examine for additional pressure ulcers?
A) Distal tips of the toes.
B) Lower abdominal folds
C) Heels and ankles
D) Thighs and calves - Answer C) Heels and ankles
Rationale: The pressure ulcers tend to form around bony prominences: heels, and the
sacrum. The pressure ulcers most commonly occur over bony prominences; however,
the RN should perform a complete skin assessment.
After examining these high-risk areas the nurse does not observe any redness;
however, the underlying tissue feels spongy. The nurse
A) Initiate the use of heat to these areas to eliminate the edema that has developed?
B) Notify the physician that the client has too much fluid in his body
C) Instruct the client that there is no pressure impairment in these areas.
D) Note these areas as areas where pressure impairment have taken place. -Answer D)
Note these areas as areas where pressure impairment have taken place.
Rationale: Pressure damage is indicated by palpable changes in the underlying tissue
consistency of a bony prominence. These changes are often described as :spongy" or
"beefy." The additional manifestations include a change in skin temperature and
induration.
The nurse chooses a priority problem for Aaron's plan of care as "Impaired skin
integrity". The nurse should choose what etiology?
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