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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. McBurney's point on the abdomen: McBurney's point is a location in the right lower quadrant of the abdomen that is significant in the assessment for appendicitis. It is not relevant to the assessment of pyelonephritis, which is a kidney infection.

B. Psoas sign at the knee: The psoas sign is a test for appendicitis, not pyelonephritis. It involves the patient lying on their back and lifting their right leg against resistance. If this movement causes pain in the lower right abdomen, it could indicate irritation of the psoas muscle due to an inflamed appendix.

C. Rovsing's Sign on the abdomen: Rovsing's sign is also a test for appendicitis. It involves palpating the left lower quadrant of the abdomen and observing if it causes pain in the right lower quadrant. The presence of pain in the right lower quadrant during palpation of the left lower quadrant can indicate appendicitis. This sign is not specific to pyelonephritis.

D. Costovertebral angle (CVA) on the back: The CVA is located on the back at the angle formed by the 12th rib and the spine. Percussion of the CVA is a common technique used to assess for kidney tenderness. In the case of acute pyelonephritis, infection and inflammation of the kidneys can cause tenderness and pain in the CVA area. Therefore, this area is assessed for pain related to kidney infections like pyelonephritis.

Correct Answer is ["165"]

Explanation

To calculate the low range of the dosage, we need to use the lower end of the dosage range provided (1.5 mg/kg) and the client's weight in kilograms.

1 lb is approximately equal to 0.45 kg. So, to convert the client's weight from pounds to kilograms:

245 lbs * 0.45 kg/lb = 110.25 kg

Now, to calculate the low range dosage:

Low range dosage = 1.5 mg/kg * 110.25 kg = 165.375 mg

Rounding to the nearest whole number, the nurse should administer 165 mg for the low range of the dosage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with acute pyelonephritis. Which area should the nurse percuss to assess for pain related to pyelonephritis?

Correct Answer is D

Explanation

A nurse is caring for a client who has a pulmonary embolism and has a new prescription for enoxaparin 1.5-2.5mg/kg subcutaneous. The client weighs 245 lbs. How many mg should the nurse administer for the low range of the dosage range? (Round the answer to the nearest whole number.)

Correct Answer is ["165"]

Explanation

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