The nurse is caring for a client who is diagnosed with an arterial insufficiency ulcer. The nurse should plan interventions to address which priority issue?
Chronic pain
Impaired skin integrity
Risk for injury
Ineffective tissue perfusion
The Correct Answer is D
A. Chronic pain - Chronic pain is a concern for the client, but addressing the underlying issue of ineffective tissue perfusion will help alleviate pain by promoting healing and reducing tissue damage.
B. Impaired skin integrity - Impaired skin integrity is a result of ineffective tissue perfusion. By addressing perfusion issues, skin integrity can be improved as tissues receive adequate oxygen and nutrients for healing.
C. Risk for injury - While clients with arterial insufficiency ulcers are at risk for injury, the immediate concern is addressing the ineffective tissue perfusion to prevent complications related to poor circulation, such as tissue necrosis and infection.
D. Ineffective tissue perfusion- Arterial insufficiency ulcers are caused by inadequate blood flow to the tissues. The priority issue for a client with an arterial insufficiency ulcer is ineffective tissue perfusion. Due to decreased blood flow, tissues do not receive enough oxygen and nutrients, leading to delayed wound healing, tissue damage, and potential complications. Interventions should focus on improving circulation, promoting vasodilation, and enhancing perfusion to facilitate wound healing and prevent further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["250"]
Explanation
To calculate the infusion rate, you first need to determine the total volume to be infused and the total time over which the infusion will occur.
Three 1L bags need to be infused over 12 hours.
Total volume = 3 bags * 1000 mL/bag = 3000 mL
Total time = 12 hours
Now, to find the rate in milliliters per hour (mL/h), divide the total volume by the total time:
Infusion rate = Total volume / Total time
Infusion rate = 3000 mL / 12 hours = 250 mL/h
Correct Answer is A
Explanation
A. Calcium Oxalate
The most common substance found in the analysis of renal stones is calcium oxalate. Calcium oxalate stones are the most prevalent type of kidney stones, accounting for the majority of cases. These stones can form when there is an excess of calcium or oxalate in the urine, and they can vary in size and shape. Other types of kidney stones include uric acid stones, struvite stones (magnesium-ammonium phosphate), and cystine stones, but calcium oxalate stones are the most common.
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