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 D

Explanation

Choice A rationale: Placing the client in reverse Trendelenburg position is not the first priority; protecting the wound is more critical.

Choice B rationale: Administering IV antibiotics STAT is not the first priority in the presence of evisceration.

Choice C rationale: Using sterile gloves to replace the protruding parts is not the first intervention; covering the wound takes precedence.

Choice D rationale: Applying a sterile normal saline dressing is the first priority to cover and protect the exposed abdominal contents.

A. stimulate deeper inhalations. B. improve ciliary movement in the bronchioles. C. loosen secretions in congested areas. D. propel oxygen along the respiratory tract.

Correct Answer is C

Explanation

Choice A rationale: Stimulating deeper inhalations is a secondary benefit of CPT, but the primary purpose is to loosen secretions in congested areas.

Choice B rationale: Improving ciliary movement in the bronchioles is a secondary benefit of CPT, but the primary purpose is to loosen secretions.

Choice C rationale: Loosening secretions in congested areas is the primary purpose of CPT for clients with pneumonia.

Choice D rationale: Propelling oxygen along the respiratory tract is not the primary purpose of CPT but may be a secondary benefit.

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

Correct Answer is D

Explanation

Chest physiotherapy (CPT) is ordered for a client with pneumonia. The nurse knows that the primary purpose of CPT for this client is to:

Correct Answer is C

Explanation

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