HESI FUNDAMENTALS PROCTORED EXAM1.The nurse is admitting an older patient from a nursing home. During theassessment, the nurse notes a shallow open reddish, pink ulcer without slough onthe right heel of the patient. How will the nurse stage this pressure ulcer?a.Stage Ib.Stage IIc.Stage IIId.Stage IVANS: BThis would be a Stage II pressure ulcer because it presents as partial-thicknessskin loss involving epidermis and dermis. The ulcer presents clinically as anabrasion, blister, or shallow crater. Stage I is intact skin with nonblanchableredness over a bony prominence. With a Stage III pressure ulcer, subcutaneousfat may be visible, but bone, tendon, and muscles are not exposed. Stage IVinvolves full-thickness tissue loss with exposed bone, tendon, or muscle.2.The nurse is completing a skin assessment on a patient with darklypigmented skin. Which item should the nurse usefirstto assist in staging anulcer on this patient?a.Disposable measuring tapeb.Cotton-tipped applicatorc.Sterile glovesd.Halogen lightANS: DWhen assessing a patient with darkly pigmented skin, proper lighting is essentialto accurately complete the first step in assessment—inspection—and the entireassessment process. Natural light or a halogen light is recommended. Fluorescentlight sources can produce blue tones on darkly pigmented skin and can interferewith an accurate assessment. Other items that could possibly be used during thePreview Mode
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