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 ["200"]
Explanation
To calculate the rate at which the nurse should program the pump in milliliters per hour, you can use the following formula:
Rate (mL/hour) = Volume (mL) / Time (hours)
In this case, the volume is 1,000 mL (1 liter), and the time is 5 hours. Plugging these values into the formula:
Rate (mL/hour) = 1,000 mL / 5 hours = 200 mL/hour
So, the nurse should program the pump to administer the normal saline at a rate of 200 milliliters per hour.
Correct Answer is B
Explanation
A. Provide the client with antipyretic therapy. - Antipyretic therapy can help reduce fever, but addressing the underlying infection with antibiotics is crucial.
B. Administer antibiotics to the client. -The priority intervention for a client with acute osteomyelitis is to administer antibiotics promptly. Osteomyelitis is a severe bacterial infection of the bone, which requires aggressive antibiotic therapy to eradicate the infection. Delaying antibiotic treatment can lead to further complications and the spread of the infection.
C. Teach relaxation breathing to reduce the client's pain. - Pain management is important, but in the case of acute osteomyelitis, the priority is to eliminate the infection through antibiotics.
D. Increase the client's protein intake. - Adequate nutrition, including protein, is important for overall healing and immune function, but it is not the priority when dealing with an acute infection that requires immediate antibiotic treatment.
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