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HESI: Skin Integrity Questions and Answers Graded A+
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HESI: Skin Integrity Questions and Answers Graded A+
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HESI: Skin Integrity Questions andAnswers Graded A+
At the end of the appointment, the nurse provides client teaching about measures to
promote healing and prevent further tissue destruction. To provide pressure relief at night,
the nurse teaches Aaron to sleep in which position?
A) Supine with the head of the bed elevated?
B) Supine with a foam wedge between the knees.
C) Thirty-degree lateral inclined position
D) Full side-lying position supported with pillows. - ✔✔C) Thirty-degree lateral
inclined position
Rationale: this position best reduces pressure on bony prominences where pressure ulcers
frequently develop. Pillows and foam wedges may be used for support and protection in this
position.
Upon learning that Aaron has a pressure-reducing gel chair cushion for his wheelchair,
which action should the nurse take?
,A) Encourage him to continue to use this device in his wheelchair at all times.
B) Recommend that he replace the gel pad with a donut-shaped foam cushion.
C) Advise him to avoid the use of any form of pressure cushion on his wheelchair.
D) Teach him that regular skin moisturizer is more important than cushion use. -
✔✔A) Encourage him to continue to use this device in his wheelchair at all times.
Rationale: These cushions help redistribute weight so that is is no all on the ischium. The client
should also be instructed to shift weight frequently.
The RN teaches Aaron to apply a dressing over the sacral area. Which type of dressing is most
likey to be used of the stage 1 pressure ulcer?
A) Transparent film dressing
B) Adherent film dressing
C) Gauze dressing
D) Hydrogel covered with a foam dressing. - ✔✔A) transparent film dressing.
Rationale: This type of dressing allows for visualization of the area and protects it from shear.
The nurse teaches Aaron to apply a transparent film dressing over the sacral area and advises him
to follow which schedule for dressing changes?
A) Twice daily
B) Once daily
, C) Every third day
D) Once weekly - ✔✔D) Once weekly
The nurse observes that the sacral ulcer is open, has a crater-like appearance, and is draining a
large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is
present. Aaron is admitted to the hospital with a fever, fluid volume deficit, and possible
sepsis. What documentation best describes the drainage from Aaron's wound?
A) Infectious
B) Purulent
C) Serous
D) Sangineous - ✔✔B) Purulent
Rationale: Purulent refers to something that contains or produces pus. Pus is an indication that
an infection is likely.
Which intervention is important to reduce the effect of the diarrhea on Aaron's skin?
A) Apply a moisture-repellent ointment on intact skin areas.
B) Rinse ulcer areas with an alcohol-based solution
C) Position a plastic-line pad under the buttocks
D) Apply moist heat to the ear following exposure to feces. - ✔✔A) Apply a moisture-
repellent ointment on intact skin areas.
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