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: Under-delegation is not related to giving too much responsibility to assistive personnel; it is about appropriate delegation based on the nurse's assessment of the situation.

Choice B rationale: Trust in delegates is essential, and under-delegation is more likely related to a lack of trust or confidence in delegation.

Choice C rationale: Under-delegation can occur due to a nurse's need for perfectionism and control, leading to a reluctance to delegate tasks to others.

Choice D rationale: Nurses often have heavy workloads, and under-delegation may be a result of feeling there is not enough time to delegate effectively.

A. there is too much moisture present in the wound bed and treatment should be changed. B. the wound will require surgical debridement of the nonviable tissue at the wound edges. C. the patient requires turning and positioning every two hours. D. this is a normal finding that indicates wound healing

Correct Answer is B

Explanation

Choice A rationale: White skin around the wound edges is not necessarily indicative of too much moisture in the wound bed.

Choice B rationale: White skin around the wound edges may suggest nonviable tissue, and surgical debridement may be needed.

Choice C rationale: Turning and positioning every two hours is important for preventing pressure injuries but is not directly related to the observed skin color.

Choice D rationale: White skin around the wound edges is not a normal finding and indicates a potential issue with tissue viability.

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

Correct Answer is C

Explanation

The nurse is performing a dressing change for a patient and notices white skin around the wound edges. The nurse is aware that:

Correct Answer is B

Explanation

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