A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:

may be caused when one layer of tissue slides over another layer of tissue.

requires dressing changes twice daily to promote healing.

is usually caused by overhydration.

is a partial thickness injury caused by pressure

Answer and Explanation

The Correct Answer is A

Choice A rationale: A DTI is a type of pressure injury that occurs when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for a prolonged period of time.

Choice B rationale: Dressing changes for a DTI would depend on the severity and characteristics of the injury, but a specific frequency is not universally prescribed. Choice C rationale: A DTI is not typically caused by overhydration but is associated with pressure-related damage to underlying tissues.

Choice D rationale: DTI is not a partial thickness injury, but rather an injury to the deep layers of tissue that may not be visible on the surface. A partial thickness injury involves damage to the epidermis and/or dermis, such as a stage 2 pressure ulcer.

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Correct Answer is B

Explanation

Choice A rationale: Administration predicting overtime costs is not a recognized advantage of delegation.

Choice B rationale: Skills of the nursing team can be used more effectively, allowing tasks to be delegated to the appropriate individuals and promoting efficient care delivery.

Choice C rationale: Clients do not necessarily receive less attention due to delegation if it is done effectively.

Choice D rationale: Nurses reporting more pressure to perform necessary tasks themselves is not a recognized advantage of delegation.

A. ineffective gas exchange. B. ineffective breathing pattern C. activity intolerance. D. decreased cardiac function

Correct Answer is B

Explanation

Choice A rationale: Ineffective gas exchange is related to respiratory issues but may not be the priority in this case.

Choice B rationale: Ineffective breathing pattern is the priority problem, as evidenced by shallow respirations and reluctance to perform coughing and deep breathing, which can lead to respiratory complications.

Choice C rationale: Activity intolerance is not the priority problem based on the given data.

Choice D rationale: Decreased cardiac function is not the priority problem based on the given data.

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A nurse is admitting a patient who has a DTI (deep tissue injury) to the hospital. The nurse understands that a DTI:

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An advantage of delegation in client care is that:

Correct Answer is B

Explanation

A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

Correct Answer is B

Explanation

The nursing assessment finding that represents the most serious indication of a client's deteriorating oxygenation status is:

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