A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:

may be caused when one layer of tissue slides over another layer of tissue.

requires dressing changes twice daily to promote healing.

is usually caused by overhydration.

is a partial thickness injury caused by pressure

Answer and Explanation

The Correct Answer is A

Choice A rationale: A DTI is a type of pressure injury that occurs when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for a prolonged period of time.

Choice B rationale: Dressing changes for a DTI would depend on the severity and characteristics of the injury, but a specific frequency is not universally prescribed. Choice C rationale: A DTI is not typically caused by overhydration but is associated with pressure-related damage to underlying tissues.

Choice D rationale: DTI is not a partial thickness injury, but rather an injury to the deep layers of tissue that may not be visible on the surface. A partial thickness injury involves damage to the epidermis and/or dermis, such as a stage 2 pressure ulcer.

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Correct Answer is B

Explanation

Choice A rationale: Poor tissue perfusion from circulatory insufficiency can affect oxygenation, but fluid in the lungs primarily impacts gas exchange at the alveolar level.

Choice B rationale: Decreased diffusion of oxygen from the alveoli to the blood is a major factor affecting oxygenation when fluid is present in the lungs.

Choice C rationale: Lowered oxygen carrying capacity can affect oxygenation but is not the primary concern in the presence of fluid in the lungs.

Choice D rationale: Decreased concentration of oxygen in the air is not the primary factor affecting oxygenation in a client with fluid in the lungs.

A. Trendelenberg position. B. side-lying position. C. supine position. D. semi-Fowler's position.

Correct Answer is D

Explanation

Choice A rationale: The Trendelenberg position is not typically used for dyspnea; it involves placing the body in a supine position with the lower half tilted downward. Choice B rationale: The side-lying position is not typically used for dyspnea.

Choice C rationale: The supine position may worsen dyspnea, especially in individuals with respiratory distress.

Choice D rationale: The semi-Fowler's position, with the head of the bed elevated, is often used to assist with breathing and improve oxygenation in clients with dyspnea.

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A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:

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Naxlex Comprehensive Predictor Exams

The nurse understands that the major factor affecting oxygenation in a client who has fluid in the lungs is:

Correct Answer is B

Explanation

The nurse finds a client on bed rest experiencing clear signs of dyspnea. The nurse should assist the client to a:

Correct Answer is D

Explanation

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