HESI Comprehensive Exam A Practice Questions & Answers 1. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Assess the skin every 4 hours. b. Limit the amount of f... luid intake. c. Use a standardized tool such as the Braden Scale. d. Have special times for inspection so as to not interrupt routine care. ANS: C Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care. 2. The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings? a. These are normal signs of aging. b. These are early signs of dementia. c. These are purely psychological in origin. d. These are common manifestation with UTIs. [Show More]
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