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: Heat therapy is generally contraindicated for a wound that is bleeding, as it can increase bleeding.

Choice B rationale: Heat therapy may not be appropriate for a client with impaired sensation due to the risk of burns.

Choice C rationale: The client who is experiencing spasms of the calf muscles can benefit from heat therapy, which can help relax the muscles and reduce pain. Heat therapy increases blood flow and oxygen delivery to the affected area, which promotes healing and reduces inflammation.

Choice D rationale: Heat therapy is contraindicated for the client who has an active, localized inflammation (D), because heat can worsen the inflammation and increase the risk of infection.

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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Naxlex Comprehensive Predictor Exams

The nurse recognizes that the application of heat therapy is appropriate for which client? The client who:

Correct Answer is C

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 nurse is caring for a client who has been wearing a nitroglycerin patch and receives an order to start a nitroglycerin intravenous Infusion. The old patch must be removed from the client's body in order to avoid:

A client must receive eyedrops bilaterally four times a day. The medication should be dropped onto which of the following areas?

A nurse is caring for a client being treated for hypernatremia. Which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

The nurse recognizes that the client is manifesting early signs of hypoxia when the assessment data includes:

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The nurse recognizes ten "rights" associated with giving medications to clients. Which are included in this group? (SELECT ALL THAT APPLY)

The nurse is aware that a common cause of under delegation in client care is:

The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?