HESI FUNDAMENTALS
PROCTORED EXAM
2023 LATEST 1. The nurse is admitting an older patient from a nursing home. During the assessment,
the nurse notes a
... [Show More] shallow open reddish, pink ulcer without slough on
the right 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-thicknessskin 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, subcutaneousfat 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 anulcer 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 essentialto accurately
complete the first step in assessment—inspection—and the entire assessment process. Natural
light or a halogen light is recommended. Fluorescentlight sources can produce blue tones on
A+
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darkly pigmented skin and can interfere with an accurate assessment. Other items that could
possibly be used during the
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185
assessment include gloves for
A+
infection control, a disposable measuring device to measure the size ofthe wound,
and a cotton-tipped applicator to measure the depth of the wound, but these items are
not the first items used.
3. The nurse is caring for a patient with a Stage IV pressure ulcer.
Which type of healing will the nurse consider when planning care forthis
patient?
a. Partial-thickness wound repair
b. Full-thickness wound repair
c. Primary intention
d. Tertiary intention
ANS: B
Stage IV pressure ulcers are full-thickness wounds that extend into the dermis and heal by
scar formation because the deeper structures do not regenerate, hence the need for fullthickness repair. The full-thickness repair has four phases: hemostasis, inflammatory,
proliferative, and maturation. A wound heals by primary intention when wounds such as
surgical wounds have little tissue loss; the skin edges are approximated or closed, and the
risk for infectionis low. Partial-thickness repairs are done on partial-thickness wounds that
are shallow, involving loss of the epidermis and maybe partial loss of the dermis.
These wounds heal by regenerati [Show Less]