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 ["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.
Correct Answer is C
Explanation
A. Increased thickness of the subcutaneous skin layer - Aging typically results in thinning of the skin and subcutaneous tissue, making older adults more vulnerable to pressure ulcers rather than having increased thickness.
B. Changes in the character and quantity of bacterial skin flora - This is a common age-related change; however, it is not directly related to the course of treatment for a sacral pressure ulcer. Proper wound care can mitigate the impact of changes in skin flora.
C. Increased time required for wound healing - Aging often leads to a decline in the body's ability to repair and regenerate tissues, which can prolong the healing process of wounds, including pressure ulcers. Older adults may experience delayed wound healing compared to younger individuals.
D. Increased elasticity of the skin - Skin elasticity decreases with age, making older adults more susceptible to skin breakdown and pressure ulcers due to reduced skin resilience and ability to redistribute pressure. Increased elasticity would not affect the course of treatment positively but rather negatively in this context.
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