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 B
Explanation
A. "I will need to drink apple cider vinegar each day."
This statement is incorrect. Drinking apple cider vinegar is not a proven method to prevent urinary tract infections (UTIs). The client does not need to consume apple cider vinegar as a preventive measure for UTIs.
B. “I will need to wipe my perineal area from back to front after urination."
This statement is incorrect and indicates a need for further teaching. Proper hygiene is essential in preventing UTIs, and wiping from back to front can introduce bacteria from the anal area to the urethra, increasing the risk of UTIs. The correct technique is to wipe from front to back after urination to prevent the spread of bacteria.
C. “I need to drink 8 cups of liquid each day."
This statement is correct. Staying well-hydrated by drinking an adequate amount of fluids, such as 8 cups of liquid each day, can help flush out bacteria from the urinary tract and reduce the risk of UTIs. Proper hydration is a good preventive measure.
D. "I will need to empty my bladder regularly and completely.”
This statement is correct. Emptying the bladder regularly and completely helps prevent the accumulation of bacteria in the urinary tract. Incomplete emptying of the bladder can allow bacteria to multiply, increasing the risk of UTIs. Regular and thorough emptying of the bladder is an important preventive measure against UTIs.
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.
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