*NURSING > HESI > HESI FUNDAMENTALS PROCTORED EXAM.Chamberlain College of NursingSchool name NURSING HESI. (All)
HESI FUNDAMENTALS PROCTORED EXAM 1. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the righ... t heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV ANS: B This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle. 2. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient? a. Disposable measuring tape b. Cotton-tipped applicator c. Sterile gloves d. Halogen light ANS: D When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the entire assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the [Show More]
Last updated: 1 year ago
Preview 1 out of 14 pages
Connected school, study & course
About the document
Uploaded On
Aug 23, 2022
Number of pages
14
Written in
This document has been written for:
Uploaded
Aug 23, 2022
Downloads
0
Views
62
In Browsegrades, a student can earn by offering help to other student. Students can help other students with materials by upploading their notes and earn money.
We're available through e-mail, Twitter, Facebook, and live chat.
FAQ
Questions? Leave a message!
Copyright © Browsegrades · High quality services·