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 C

Explanation

Choice A rationale: The deltoid muscle may not accommodate larger volumes as comfortably as other sites.

Choice B rationale: The dorsogluteal site is not recommended due to the risk of injury to the sciatic nerve.

Choice C rationale: The ventrogluteal site is the preferred site for IM injections in adults, providing a safe and well-vascularized muscle.

Choice D rationale: The vastus lateralis is a suitable site for infants and young children but may not be the most comfortable for adults receiving a 2 mL injection.

A. Instruct client to shift their weight at least every 15 minutes B. Keep head of bed raised at 45 degrees at all times C. Massage over bony prominences every hour while awake D. Apply moisture barrier cream to perineal skin E. Consult with the wound care nurse about use of a specialty mattress

Correct Answer is ["A","D","E"]

Explanation

Choice A rationale: Instructing the client to shift their weight at least every 15 minutes helps prevent pressure injuries.

Choice B rationale: Keeping the head of the bed raised at 45 degrees at all times is not a typical practice for preventing pressure injuries.

Choice C rationale: Massaging over bony prominences every hour while awake may not be recommended, as this can cause friction and shear, contributing to skin breakdown. Choice D rationale: Applying moisture barrier cream to perineal skin helps protect against skin breakdown from urinary incontinence.

Choice E rationale: Consulting with the wound care nurse about the use of a specialty mattress can provide additional support and help prevent pressure injuries.

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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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The nurse is to administer a volume of 2 mL intramuscularly (IM) to a 150-pound client. Assuming that there are no skin problems, which is the preferred site for the injection?

Correct Answer is C

Explanation

Correct Answer is ["A","D","E"]

Explanation

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