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How to measure skin integrity with a Hesi flashcard?
A) Apply light pressure to the area with the fingertips. B) Measure the diameter of the redness. B) Observe for wound approximation. D) Gently lift a fold of skin. A) Apply light pressure to the area with the fingertips. Rationale: The RN applies light pressure with the fingertips to asses for blanching.
What do you need to know about skin integrity?
A) Provide verbal instructions about positioning to the UAP and document the instructions in the nurse's notes. C) Advise the charge nurse that client confidentiality is secondary to the continuity of care. D) Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.
Who is Aaron Brown from the Hesi flashcards?
Aaron Brown is a 23-year-old Caucasian male with paraplegia as the result of a spinal cord injury received in a boating accident. He lives at home with his parents while attending college. He visits the Health Clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum.
How to observe for wound approximation with Hesi?
B) Observe for wound approximation. D) Gently lift a fold of skin. A) Apply light pressure to the area with the fingertips. Rationale: The RN applies light pressure with the fingertips to asses for blanching. This is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairment.
Last Update: Oct 2021
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