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 ["500"]
Explanation
To calculate the infusion rate in ml/hr for a 500 ml bolus to be administered over 1 hour, you can simply set the pump to deliver the entire volume in the specified time:
500 ml / 1 hour = 500 ml/hr
So, the pump should be set at 500 ml/hr to administer the 500 ml bolus over 1 hour.
Correct Answer is A
Explanation
Explanation:
A. Promptly inform the primary provider:
Explanation: Compartment syndrome is a medical emergency that requires immediate intervention. If a nurse suspects compartment syndrome due to symptoms like severe unrelieved pain, absent pulses, and pale extremities, the most appropriate action is to promptly inform the primary healthcare provider. The provider can assess the situation, order necessary diagnostic tests, and potentially arrange for emergent interventions like fasciotomy to relieve compartment pressure.
B. Reassess the client's neurovascular status in 15 minutes:
Explanation: Waiting for 15 minutes to reassess the client's neurovascular status is not appropriate in this situation. Compartment syndrome can progress rapidly, leading to irreversible tissue damage within a short time frame. Delaying assessment and intervention can result in significant complications.
C. Warm the client's foot and determine whether circulation improves:
Explanation: Warming the foot is not appropriate in this context. Compartment syndrome is caused by increased pressure within the muscle compartment, leading to compromised circulation. Warming the foot will not address the underlying issue of elevated compartment pressure and can potentially worsen the condition by dilating blood vessels and increasing pressure further.
D. Reposition the client with the affected foot dependent:
Explanation: Repositioning the client with the affected foot dependent is contraindicated in compartment syndrome. Elevating the limb can worsen the condition by further restricting blood flow. The limb should be kept at or slightly below the level of the heart to maintain adequate perfusion until medical intervention can be initiated.
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