HESI SKIN INTEGRITY AND RATIONALE LATEST FINAL EXAM UPDATED FOR 2026 2026 TOP SCORE COMPREHENSIVE QUESTIONS WITH 100% CERTIFIED, DETAILED & VERIFIED SOLUTIONS, ACE YOUR EXAMS- DEFINITE SUCCESS!!!

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HESI SKIN INTEGRITY AND RATIONALE LATEST FINAL EXAM UPDATED FOR 2025 2026 TOP SCORE COMPREHENSIVE QUESTIONS WITH 100% CERTIFIED, DETAILED & VERIFIED SOLUTIONS, ACE YOUR EXAMS- DEFINITE SUCCESS!!! In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? -Apply light pressure to the area with the fingertips. -Measure the diameter of the redness. (The area of redness should be measured to evaluate progression or healing. The nurse applies light pressure with the fingertips to assess for blanching. Blanching is a normal response that indicates there is no tissue perfusion impairment.) 2. 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? Reactive hyperemia. (Reactive hyperemia occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than 1 hour and the surrounding tissue does not blanch.) 3. Which areas are most important for the nurse to observe for additional pressure ulcers? Ischial tuberosities. Pressure ulcers typically occur over bony prominences, such as the heels, ankles, ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial tuberosities at greater risk for breakdown. While bony prominences are the most common sites for pressure ulcer development, the nurse should perform a complete skin assessment. 4. During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement? Identify these areas as sites where pressure damage has occurred. (Palpable changes in the consistency of the tissue underlying a bony prominence, often described as "spongy," is an indication that pressure damage has occurred. Additional manifestations may include a change in skin temperature and induration.)

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