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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Changing the soiled dressing carefully is important but not specifically associated with caring for a Penrose drain.
Choice B rationale: Pinning the drain to the dressing is not typically done; securing the drain and preventing tension are important.
Choice C rationale: Allowing the drain reservoir to fill completely before emptying it is a crucial nursing action associated with caring for a Penrose drain.
Choice D rationale: Maintaining the negative pressure of the drain is not applicable to a Penrose drain, which relies on gravity drainage.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale: Compensating for an ongoing problem affecting other fluid or electrolytes is a common rationale for IV therapy.
Choice B rationale: Increasing urine specific gravity to 1.045 is not a typical goal for IV therapy. IV therapy would decrease the urine specific gravity by diluting the urine with fluids.
Choice C rationale: Moving fluid into an area that is physiologically unavailable is not a primary goal of IV therapy. Physiologically unavailable areas are those that are separated from the rest of the body by a membrane or barrier, such as the cerebrospinal fluid, the intraocular fluid, or the pleural fluid. IV therapy does not cross these barriers and only affects the intravascular and interstitial spaces.
Choice D rationale: Correcting imbalance in fluid and electrolytes is a primary goal of IV therapy.
Choice E rationale: Expanding intravascular volume is a common goal of IV therapy, especially in cases of dehydration or hypovolemia.
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