The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Risk for Injury

Altered Tissue Perfusion

Impaired Tissue Integrity

Impaired Skin Integrity

Answer and Explanation

The Correct Answer is D

A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reﬂects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

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Correct Answer is D

Explanation

The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight oﬀ the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.

A. "These exercises prevent thrombophlebitis." B. "The doctor ordered the exercises." C. "These exercises help prevent pneumonia." D. "All surgical clients must do these exercises." E. The correct answer and explanation is:

Correct Answer is C

Explanation

Turning, deep breathing, and coughing exercises are important for clients recovering from surgery as they help prevent the development of pneumonia. After surgery, clients may have difficulty taking deep breaths and coughing due to pain or discomfort. This can lead to the accumulation of mucus in the lungs, increasing the risk of pneumonia. By performing these exercises, clients can help clear their lungs and reduce their risk of developing this complication. While these exercises may also help prevent other complications such as thrombophlebitis, the primary reason for performing them is to prevent pneumonia.

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The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

Correct Answer is D

Explanation

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. How should the nurse respond?

Correct Answer is C

Explanation

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